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Oreskovic J, Kaufman J, Thommandram A, Fossat Y. A Radar-Based Opioid Overdose Detection Device for Public Restrooms: Design, Development, and Evaluation Study. JMIR BIOMEDICAL ENGINEERING 2023; 8:e51754. [PMID: 38875668 PMCID: PMC11041516 DOI: 10.2196/51754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 09/27/2023] [Accepted: 10/06/2023] [Indexed: 06/16/2024] Open
Abstract
BACKGROUND The opioid epidemic is a growing crisis worldwide. While many interventions have been put in place to try to protect people from opioid overdoses, they typically rely on the person to take initiative in protecting themselves, requiring forethought, preparation, and action. Respiratory depression or arrest is the mechanism by which opioid overdoses become fatal, but it can be reversed with the timely administration of naloxone. OBJECTIVE In this study, we described the development and validation of an opioid overdose detection radar (ODR), specifically designed for use in public restroom stalls. In-laboratory testing was conducted to validate the noncontact, privacy-preserving device against a respiration belt and to determine the accuracy and reliability of the device. METHODS We used an ODR system with a high-frequency pulsed coherent radar sensor and a Raspberry Pi (Raspberry Pi Ltd), combining advanced technology with a compact and cost-effective setup to monitor respiration and detect opioid overdoses. To determine the optimal position for the ODR within the confined space of a restroom stall, iterative testing was conducted, considering the radar's bounded capture area and the limitations imposed by the stall's dimensions and layout. By adjusting the orientation of the ODR, we were able to identify the most effective placement where the device reliably tracked respiration in a number of expected positions. Experiments used a mock restroom stall setup that adhered to building code regulations, creating a controlled environment while maintaining the authenticity of a public restroom stall. By simulating different body positions commonly associated with opioid overdoses, the ODR's ability to accurately track respiration in various scenarios was assessed. To determine the accuracy of the ODR, testing was performed using a respiration belt as a reference. The radar measurements were compared with those obtained from the belt in experiments where participants were seated upright and slumped over. RESULTS The results demonstrated favorable agreement between the radar and belt measurements, with an overall mean error in respiration cycle duration of 0.0072 (SD 0.54) seconds for all recorded respiration cycles (N=204). During the simulated overdose experiments where participants were slumped over, the ODR successfully tracked respiration with a mean period difference of 0.0091 (SD 0.62) seconds compared with the reference data. CONCLUSIONS The findings suggest that the ODR has the potential to detect significant deviations in respiration patterns that may indicate an opioid overdose event. The success of the ODR in these experiments indicates the device should be further developed and implemented to enhance safety and emergency response measures in public restrooms. However, additional validation is required for unhealthy opioid-influenced respiratory patterns to guarantee the ODR's effectiveness in real-world overdose situations.
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Affiliation(s)
| | | | | | - Yan Fossat
- Klick Labs, Klick Inc, Toronto, ON, Canada
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Dos Santos M, Girard G, Briand Madrid L, Perreaut L, Olenine A, Roux P. "The Slums Have To Be Shown": Documenting Drug Injection in Public Spaces Ahead of the Opening of a Drug Consumption Room in Marseille. QUALITATIVE HEALTH RESEARCH 2023:10497323231169607. [PMID: 37271754 DOI: 10.1177/10497323231169607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
EPOSIM is a community-based participatory research study which used the Photovoice method with people who inject drugs (PWID) ahead of a possible opening of a drug consumption room (DCR) in Marseille, France. It aimed to identify the strategies used by PWID when injecting, and the risks they take when they have no safe private space to inject in the area they live in. A total of 7 PWID participated in the full study process. The 189 photographs they took provided us with a good understanding of their injection practices in public places. The main results highlighted the spatiality and materiality of injecting experience in a context where no DCR was available. They also showed the relevance of Photovoice to valorize the voices of PWID when implementing a DCR. Through the showcasing of their photographs at various public exhibitions, the participants seized the opportunity to use Photovoice to make their voices heard beyond the group formed for the study, in order to show the different forms of stigma and insalubrious contexts which they faced on a daily basis. Furthermore, the photographs taken demonstrated that having only health and safety records is not enough to fully understand PWID injection practices. Future studies must take into account PWID perceptions of their relationship with injecting in public spaces and with the management of stigma. The questions of pleasure and comfort must also be explored in evaluation studies of harm reduction measures, for example, DCR.
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Affiliation(s)
- Marie Dos Santos
- Aix Marseille Univ, INSERM, IRD, SESSTIM, Sciences Economiques and Sociales de la Santé and Traitement de l'Information Médicale, Faculté de médecine, Marseille, France
| | - Gabriel Girard
- Aix Marseille Univ, INSERM, IRD, SESSTIM, Sciences Economiques and Sociales de la Santé and Traitement de l'Information Médicale, Faculté de médecine, Marseille, France
| | - Laélia Briand Madrid
- Aix Marseille Univ, INSERM, IRD, SESSTIM, Sciences Economiques and Sociales de la Santé and Traitement de l'Information Médicale, Faculté de médecine, Marseille, France
| | - Lola Perreaut
- Asud Mars Say Yeah Harm Reduction, Marseille, France
| | | | - Perrine Roux
- Aix Marseille Univ, INSERM, IRD, SESSTIM, Sciences Economiques and Sociales de la Santé and Traitement de l'Information Médicale, Faculté de médecine, Marseille, France
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Giglio RE, Mantha S, Harocopos A, Saha N, Reilly J, Cipriano C, Kennelly M, Landau L, McRae M, Chokshi DA. The Nation's First Publicly Recognized Overdose Prevention Centers: Lessons Learned in New York City. J Urban Health 2023; 100:245-254. [PMID: 37016269 PMCID: PMC10072795 DOI: 10.1007/s11524-023-00717-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/13/2023] [Indexed: 04/06/2023]
Abstract
In November of 2021, multiple factors converged to create a window of opportunity to open overdose prevention centers (OPCs) at two existing syringe service programs (SSPs) in New York City (NYC). Political will exists in NYC, particularly toward the end of the de Blasio administration's term, and the NYC Health Department worked to garner additional support from local and state elected officials given the dire need to address the overdose crisis. This coincided with readiness on the part of one of the NYC SSP providers, OnPoint NYC, to open and operate OPC services. Legal risks were assessed by both the city and the provider. This case study outlines the sequence of events that resulted in NYC supporting OnPoint to open the first two publicly recognized OPCs in the nation, including lessons learned to inform other jurisdictions considering offering such services.
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Affiliation(s)
- Rebecca E Giglio
- New York City Department of Health and Mental Hygiene, Queens 42-09 28Th St, New York, NY, 11101, USA.
| | - Shivani Mantha
- New York City Department of Health and Mental Hygiene, Queens 42-09 28Th St, New York, NY, 11101, USA
| | - Alex Harocopos
- New York City Department of Health and Mental Hygiene, Queens 42-09 28Th St, New York, NY, 11101, USA
| | - Nilova Saha
- New York City Department of Health and Mental Hygiene, Queens 42-09 28Th St, New York, NY, 11101, USA
| | - Jacqueline Reilly
- New York City Department of Health and Mental Hygiene, Queens 42-09 28Th St, New York, NY, 11101, USA
| | - Chelsea Cipriano
- New York City Department of Health and Mental Hygiene, Queens 42-09 28Th St, New York, NY, 11101, USA
| | - Maura Kennelly
- New York City Department of Health and Mental Hygiene, Queens 42-09 28Th St, New York, NY, 11101, USA
| | - Lisa Landau
- New York City Department of Health and Mental Hygiene, Queens 42-09 28Th St, New York, NY, 11101, USA
| | - Michael McRae
- New York City Department of Health and Mental Hygiene, Queens 42-09 28Th St, New York, NY, 11101, USA
| | - Dave A Chokshi
- New York Health Foundation, New York, NY, USA
- New York University Grossman School of Medicine, New York, NY, USA
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4
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Modeling of overdose and naloxone distribution in the setting of fentanyl compared to heroin. Drug Alcohol Depend 2022; 236:109478. [PMID: 35588609 PMCID: PMC9235402 DOI: 10.1016/j.drugalcdep.2022.109478] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 04/22/2022] [Accepted: 04/25/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND Fentanyl has replaced most other non-prescribed opioids in much of North America. There is controversy over whether a hypothetical reduced efficacy of naloxone in reversing fentanyl is a major contributor to the coincident rising overdose mortality. METHODS We modified an existing Markov decision analytic model of heroin overdose and naloxone distribution to account for known risks of fentanyl by adjusting overdose risk, the likelihood of death in the event of overdose, and the proportion of cases in which available naloxone was administered in time to prevent death. We assumed near-universal survival when naloxone was administered promptly for heroin or fentanyl overdose, but allowed that to decline in sensitivity analyses for fentanyl. We varied the proportion of use that was fentanyl and adjusted the modified parameters accordingly to estimate mortality as the dominant opioid shifted. RESULTS Absent naloxone, the annual overdose death rate was 1.0% and 4.1% for heroin and fentanyl, respectively. With naloxone reaching 80% of those at risk, the overdose death rate was 0.7% and 3.6% for heroin and fentanyl, respectively, representing reductions of 26.4% and 12.0%. Monte Carlo simulations resulted in overdose mortality with fentanyl of 3.3-5.2% without naloxone and 2.6-4.9% with naloxone, with 95% certainty. Positing reduced efficacy for naloxone in reversing fentanyl resulted in 3.6% of fentanyl overdose deaths being prevented by naloxone. CONCLUSIONS Heightened risk for overdose and subsequent death, alongside the time-sensitive need for naloxone administration, fully account for increased mortality when fentanyl replaces heroin, assuming optimal pharmacologic efficacy of naloxone.
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Roux P, Jauffret-Roustide M, Donadille C, Briand Madrid L, Denis C, Célérier I, Chauvin C, Hamelin N, Maradan G, Carrieri MP, Protopopescu C, Lalanne L, Auriacombe M. Impact of drug consumption rooms on non-fatal overdoses, abscesses and emergency department visits in people who inject drugs in France: results from the COSINUS cohort. Int J Epidemiol 2022; 52:562-576. [PMID: 35690956 DOI: 10.1093/ije/dyac120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 05/17/2022] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The effectiveness of drug consumption rooms (DCRs) for people who inject drugs (PWID) has been demonstrated for HIV and hepatitis C virus risk practices, and access to care for substance use disorders. However, data on other health-related complications are scarce. Using data from the French COSINUS cohort, we investigated the impact of DCR exposure on non-fatal overdoses, abscesses and emergency department (ED) visits, all in the previous 6 months. METHODS COSINUS is a 12-month prospective cohort study of 665 PWID in France studying DCR effectiveness on health. We collected data from face-to-face interviews at enrolment, and at 6 and 12 months of follow-up. After adjusting for other correlates (P-value < 0.05), the impact of DCR exposure on each outcome was assessed using a two-step Heckman mixed-effects probit model, allowing us to adjust for potential non-randomization bias due to differences between DCR-exposed and DCR-unexposed participants, while taking into account the correlation between repeated measures. RESULTS At enrolment, 21%, 6% and 38% of the 665 participants reported overdoses, abscesses and ED visits, respectively. Multivariable models found that DCR-exposed participants were less likely to report overdoses [adjusted coefficient (95% CI): -0.47 (-0.88; -0.07), P = 0.023], abscesses [-0.74 (-1.11; -0.37), P < 0.001] and ED visits [-0.74 (-1.27; -0.20), P = 0.007]. CONCLUSION This is the first study to show the positive impact of DCR exposure on abscesses and ED visits, and confirms DCR effectiveness in reducing overdoses, when adjusting for potential non-randomization bias. Our findings strengthen the argument to expand DCR implementation to improve PWID injection environment and health.
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Affiliation(s)
- P Roux
- Aix Marseille Univ, INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l'Information Médicale, ISSPAM, Marseille, France
| | - M Jauffret-Roustide
- Cermes3, Inserm U988/CNRS UMR 8211/EHESS/Université de Paris, Paris, France
- British Columbia Center on Substance Use, Vancouver, Canada
- Baldy Center on Law and Social Policy, Buffalo University, Buffalo, NY, USA
| | - C Donadille
- Aix Marseille Univ, INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l'Information Médicale, ISSPAM, Marseille, France
| | - L Briand Madrid
- Aix Marseille Univ, INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l'Information Médicale, ISSPAM, Marseille, France
| | - C Denis
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Univ. Bordeaux, Bordeaux, France
- Sleep, Addiction and Neuropsychiatry research laboratory (SANPSY), CNRS UMR 6033, Bordeaux, France
- Pôle Addictologie, CH Charles Perrens and CHU de Bordeaux, Bordeaux, France
| | - I Célérier
- ORS PACA, Observatoire régional de la santé Provence-Alpes-Côte d'Azur, Marseille, France
| | - C Chauvin
- Cermes3, Inserm U988/CNRS UMR 8211/EHESS/Université de Paris, Paris, France
| | - N Hamelin
- INSERM 1114, Department of Psychiatry and Addictology, University Hospital of Strasbourg, Fédération de Médecine Translationnelle de Strasbourg (FMTS), Strasbourg, France
| | - G Maradan
- ORS PACA, Observatoire régional de la santé Provence-Alpes-Côte d'Azur, Marseille, France
| | - M P Carrieri
- Aix Marseille Univ, INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l'Information Médicale, ISSPAM, Marseille, France
| | - C Protopopescu
- Aix Marseille Univ, INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l'Information Médicale, ISSPAM, Marseille, France
| | - L Lalanne
- INSERM 1114, Department of Psychiatry and Addictology, University Hospital of Strasbourg, Fédération de Médecine Translationnelle de Strasbourg (FMTS), Strasbourg, France
- Department of Psychiatry and Addictology, University Hospital of Strasbourg, Fédération de Médecine Translationnelle de Strasbourg (FMTS), Strasbourg, France
| | - M Auriacombe
- Univ. Bordeaux, Bordeaux, France
- Sleep, Addiction and Neuropsychiatry research laboratory (SANPSY), CNRS UMR 6033, Bordeaux, France
- Pôle Addictologie, CH Charles Perrens and CHU de Bordeaux, Bordeaux, France
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Ataiants J, Mazzella S, Roth AM, Robinson LF, Sell RL, Lankenau SE. Multiple Victimizations and Overdose Among Women With a History of Illicit Drug Use. JOURNAL OF INTERPERSONAL VIOLENCE 2022; 37:NP1588-NP1613. [PMID: 32536256 PMCID: PMC7808297 DOI: 10.1177/0886260520927501] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
The experiences of violence and overdose are highly prevalent among women who use illicit drugs. This study sought to ascertain whether multiple victimizations during adulthood increase the frequency of women's overdose. The sample comprised 218 women recruited at Philadelphia harm reduction sites during 2016-2017. Victimization was assessed as exposure to 16 types of adulthood violence. Three measures were constructed for multiple victimizations: continuous and categorical polyvictimization, and predominant violence domain. Negative binomial regression estimated the incidence rate ratio (IRR) of lifetime overdoses from multiple victimizations. Lifetime history of opioid use (88.6%) and drug injection (79.5%) were common. Among overdose survivors (68.5%), the median of lifetime overdoses was 3. The majority of participants (58.7%) were victims of predominantly sexual violence, 26.1% experienced predominantly physical abuse/assault, and 3.7% were victims of predominantly verbal aggression/coercive control. Participants reported a mean of seven violence types; the higher-score category of polyvictimization (9-16 violence types) comprised 41.7% of the total sample. In multivariable models, one-unit increase in continuous polyvictimization was associated with 4% higher overdose rates (IRR: 1.04, 95% confidence interval [CI]: [1.00, 1.08]). Compared to women who were not victimized (11.5%), those in the higher-score category of polyvictimization (IRR: 2.01; 95% CI: [1.06, 3.80]) and exposed to predominantly sexual violence (IRR: 2.10, 95% CI: [1.13, 3.91]) were expected to have higher overdose rates. Polyvictimization and sexual violence amplified the risk of repeated overdose among drug-involved women. Female overdose survivors need to be screened for exposure to multiple forms of violence, especially sexual violence. Findings underscore the need to scale-up victimization support and overdose prevention services for disenfranchised women.
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Supervised Injection Facilities as Harm Reduction: A Systematic Review. Am J Prev Med 2021; 61:738-749. [PMID: 34218964 PMCID: PMC8541900 DOI: 10.1016/j.amepre.2021.04.017] [Citation(s) in RCA: 57] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 03/29/2021] [Accepted: 04/19/2021] [Indexed: 11/22/2022]
Abstract
CONTEXT Supervised injection facilities are harm reduction interventions that allow people who inject drugs to use previously obtained substances under the supervision of health professionals. Although currently considered illegal under U.S. federal law, several U.S. cities are considering implementing supervised injection facilities anyway as a response to the escalating overdose crisis. The objective of this review is to determine the effectiveness of supervised injection facilities, compared with that of control conditions, for harm reduction and community outcomes. EVIDENCE ACQUISITION Studies were identified from 2 sources: a high-quality, broader review examining supervised injection facility-induced benefits and harms (from database inception to January 2014) and an updated search using the same search strategy (January 2014‒September 2019). Systematic review methods developed by the Guide to Community Preventive Services were used (screening and analysis, September 2019‒December 2020). EVIDENCE SYNTHESIS A total of 22 studies were included in this review: 16 focused on 1 supervised injection facility in Vancouver, Canada. Quantitative synthesis was not conducted given inconsistent outcome measurement across the studies. Supervised injection facilities in the included studies (n=number of studies per outcome category) were mostly associated with significant reductions in opioid overdose morbidity and mortality (n=5), significant improvements in injection behaviors and harm reduction (n=7), significant improvements in access to addiction treatment programs (n=7), and no increase or reductions in crime and public nuisance (n=7). CONCLUSIONS For people who inject drugs, supervised injection facilities may reduce the risk of overdose morbidity and mortality and improve access to care while not increasing crime or public nuisance to the surrounding community.
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Shrestha S, Stopka TJ, Hughto JMW, Case P, Palacios WR, Reilly B, Green TC. Prevalence and correlates of non-fatal overdose among people who use drugs: findings from rapid assessments in Massachusetts, 2017-2019. Harm Reduct J 2021; 18:93. [PMID: 34461922 PMCID: PMC8404353 DOI: 10.1186/s12954-021-00538-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Accepted: 08/16/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND People who experience non-fatal overdose (NFOD) are at high risk of subsequent overdose. With unprecedented increases in fentanyl in the US drug supply, many Massachusetts (MA) communities have seen a surge in opioid-related overdoses. The objective of this study was to determine factors associated with lifetime and past year NFOD in at-risk MA communities. METHODS We conducted multiple rapid assessments among people who use drugs (PWUD) in eight MA communities using non-probability sampling (purposive, chain referral, respondent-driven) methods. We collected sociodemographic, substance use, overdose history, substance use treatment, and harm reduction services utilization data. We examined the prevalence of NFOD (lifetime and past year) and identified factors associated with NFOD through multivariable logistic regression analyses in a subset of 469 study participants between 2017 and 2019. RESULTS The prevalence of lifetime and last year non-fatal opioid overdose was 62.5% and 36.9%, respectively. Many of the study participants reported heroin (64%) and fentanyl (45%) use during the 30 days preceding the survey. Nonprescription buprenorphine and fentanyl use were independently associated with higher odds of lifetime NFOD, while marijuana use was associated with lower odds of lifetime NFOD (p < 0.05). Injection as the route of administration, benzodiazepine, nonprescription buprenorphine, heroin, and fentanyl use were independently associated with higher odds, while methadone use was associated with lower odds of past year NFOD (p < 0.05). CONCLUSION We documented a high prevalence of past year and lifetime NFOD among PWUD in MA. Our findings provide indicators that can help inform interventions to prevent overdoses among PWUD, including overdose prevention, medication treatment, and naloxone distribution.
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Affiliation(s)
- Shikhar Shrestha
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, USA
| | - Thomas J Stopka
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, USA
| | - Jaclyn M W Hughto
- Departments of Behavioral and Social Sciences and Epidemiology, Brown University School of Public Health, Center for Health Promotion and Health Equity, Brown University, Providence, RI, USA
| | - Patricia Case
- Bouvé College of Health Sciences, Northeastern University, Boston, MA, USA
| | - Wilson R Palacios
- School of Criminology and Justice Studies, University of Massachusetts, Lowell, MA, USA
| | - Brittni Reilly
- Massachusetts Department of Public Health, Bureau of Substance Addiction Services, Boston, MA, USA
| | - Traci C Green
- Opioid Policy Research Collaborative, Heller School for Social Policy and Management, Brandeis University, Waltham, MA, USA.
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Bennett AS, Elliott L. Naloxone's role in the national opioid crisis-past struggles, current efforts, and future opportunities. Transl Res 2021; 234:43-57. [PMID: 33684591 PMCID: PMC8327685 DOI: 10.1016/j.trsl.2021.03.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 02/28/2021] [Accepted: 03/01/2021] [Indexed: 02/05/2023]
Abstract
Over the past 25 years, naloxone has emerged as a critical lifesaving overdose antidote. Public health advocates and community activists established early methods for naloxone distribution to people who inject drugs, but a legacy of stigmatization and opposition to universal naloxone access continues to limit the drug's full potential to reduce opioid-related mortality. The establishment of naloxone distribution programs under the umbrella of syringe exchange programs faces the same practical, ideological and financial barriers to expansion similar to those faced by syringe exchange programs themselves. The expansion of naloxone from the confines of a few syringe exchange programs to what we see today represents an enormous triumph for the grass-roots activists, service providers, and public health professionals who have fought to guarantee lay access to naloxone. Despite the extensive efforts to expand access to naloxone, naloxone continues to remains a scarce resource in many US localities. Considerable naloxone "deserts" remain and even where there is naloxone access, it does not always reach those at risk. Promising areas for expansion include the development of more robust telehealth methods for naloxone distribution, including subsidized mail delivery programs; lowering barriers to pharmacy access; working with hospitals, ambulances, and law enforcement to expand naloxone "leave behind" programs; providing naloxone co-prescription with medications for opioid use disorder; and working with prisons, shelters, and networks of people who use drugs to increase access to the lifesaving medication. Efforts to ensure over-the-counter and low- or no-cost naloxone are ongoing and stand alongside medication-assisted treatments as efficacious, readily-actionable, and cost-efficient population-level interventions available for combatting opioid-related overdose in the United States.
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Affiliation(s)
- Alex S Bennett
- Department of Social and Behavioral Sciences, College of Global Public Health, New York University, New York, New York; Center for Drug Use and HIV Research (CDUHR), College of Global Public Health, New York University, New York, New York.
| | - Luther Elliott
- Department of Social and Behavioral Sciences, College of Global Public Health, New York University, New York, New York; Center for Drug Use and HIV Research (CDUHR), College of Global Public Health, New York University, New York, New York
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10
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Armoon B, SoleimanvandiAzar N, Rostami M, Higgs P, Bayani A, Bayat AH, Mohammadi R, Ahounbar E, Fattah Moghaddam L. Drug type and risk behaviors associated with non-fatal overdose among people who use drugs: a systematic review and meta-analysis. J Addict Dis 2021; 40:114-125. [PMID: 34286664 DOI: 10.1080/10550887.2021.1950262] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
The present study aimed to determine the association between drug type, risk behaviors and non-fatal overdose among people who use drugs (PWUD). We searched for studies in English published before February 1, 2021, on PubMed, Scopus, Cochrane, and Web of Science to identify primary studies on the factors associated with non-fatal overdose among PWUD. After reviewing for study duplicates, the full-text of selected articles were assessed for eligibility using Population, Intervention, Comparator, Outcomes (PICO) criteria. After a detailed assessment of over 13,845 articles, a total of 49 studies met the eligibility criteria. We found that non-injection opioid use, heroin injection, cocaine use, concurrent use of buprenorphine and benzodiazepines, benzodiazepine use, incarceration, injecting drugs, and duration of injecting were associated with greater odds of non-fatal overdose among PWUD. The findings of the current meta-analysis support the requirement to improve suitable harm reduction strategies for drug users, such as peer-based overdose management, and further focusing on the need to balance the current emphasis on enforcement-based responses to illegal drug use with health-related interventions.
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Affiliation(s)
- Bahram Armoon
- Douglas Hospital Research Centre, Douglas Mental Health University Institute, Montreal, QC, Canada.,Department of Psychiatry, McGill University, Montreal, QC, Canada
| | - Neda SoleimanvandiAzar
- Preventive Medicine and Public Health Research Center, Psychosocial Health Research Institute, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammad Rostami
- Department of Counseling, Faculty of Humanities and Social Sciences, University of Kurdistan, Kurdistan, Iran
| | - Peter Higgs
- Department of Public Health, School of Psychology and Public Health, La Trobe University, Melbourne, VIC, Australia
| | - Azadeh Bayani
- Social Determinants of Health Research Center, Saveh University of Medical Sciences, Saveh, Iran
| | - Amir-Hossein Bayat
- Social Determinants of Health Research Center, Saveh University of Medical Sciences, Saveh, Iran
| | - Rasool Mohammadi
- Department of Biostatistics and Epidemiology, School of Public Health and Nutrition, Lorestan University of Medical Sciences, Khorramabad, Iran
| | - Elahe Ahounbar
- Substance Abuse and Dependence Research Center, The University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
| | - Ladan Fattah Moghaddam
- Department of Nursing, Faculty of Nursing and Midwifery, Tehran Medical Sciences, Islamic Azad University, Tehran, Iran
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Scheim AI, Bouck Z, Tookey P, Hopkins S, Sniderman R, McLean E, Garber G, Baral S, Rourke SB, Werb D. Supervised consumption service use and recent non-fatal overdose among people who inject drugs in Toronto, Canada. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2020; 87:102993. [PMID: 33160158 DOI: 10.1016/j.drugpo.2020.102993] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 08/21/2020] [Accepted: 09/29/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Aiming to reducing overdose mortality, over 40 supervised drug consumption services (SCS) presently operate in Canada. Arguments against SCS include the potential for increased non-fatal overdoses mediated by risk compensation. This study estimates associations between SCS use and recent non-fatal overdose among people who inject drugs (PWID). METHODS We analyzed cross-sectional baseline data collected between November 2018 and March 2020 from a cohort of adult PWID in Toronto, Canada. Recent non-fatal overdose was self-reported over the previous six months. The primary exposure was frequency of SCS use, self-reported as the proportion of injections performed at an SCS (all or most [75-100%], some [26-74%], few [≤25%], or none) in the previous six months. The prevalence of recent overdose was compared between all unique pairs of groups based on their frequency of SCS use and expressed as covariate-adjusted prevalence ratios (PR) estimated using modified Poisson regression. RESULTS Among 701 PWID (median [IQR] age, 40 [33 to 49]; 64.3% cisgender men; 56.8% injecting daily), most reported SCS use (all/most, 26.2%; some, 30.9%; few, 29.4%) versus no use (13.5%), with 38.6% reporting a recent overdose. From adjusted regression analyses, more frequent SCS use was not statistically significantly associated with overdose when compared to either no SCS use or less frequent use. Associations between SCS use frequency and overdose were notably smaller among SCS clients compared to associations between SCS clients and non-users (e.g., all/most versus none: PR, 1.43 [95% CI, 0.93 to 2.21]; all/most versus some: PR, 0.94 [95% CI, 0.75 to 1.17]; all/most versus few: PR, 1.15 [95% CI, 0.89 to 1.48]). CONCLUSION Findings did not indicate statistically significant associations between SCS use frequency and recent non-fatal overdose, particularly among SCS clients who may be more comparable. Nevertheless, overdose was common, underscoring the need to prevent non-fatal overdose and associated morbidity.
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Affiliation(s)
- Ayden I Scheim
- Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, PA, United States; Centre on Drug Policy Evaluation, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.
| | - Zachary Bouck
- Centre on Drug Policy Evaluation, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Paula Tookey
- South Riverdale Community Health Centre, Toronto, ON, Canada
| | | | - Ruby Sniderman
- Centre on Drug Policy Evaluation, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Elizabeth McLean
- Centre on Drug Policy Evaluation, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | | | - Stefan Baral
- Department of Epidemiology, Johns Hopkins University School of Public Health, Baltimore, MD, United States
| | - Sean B Rourke
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Dan Werb
- Centre on Drug Policy Evaluation, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Division of Infectious Diseases and Global Public Health, University of California San Diego School of Medicine, La Jolla, CA, United States
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12
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Otachi JK, Vundi N, Surratt HL. Examining Factors Associated with Non-Fatal Overdose among People Who Inject Drugs in Rural Appalachia. Subst Use Misuse 2020; 55:1935-1942. [PMID: 32552243 PMCID: PMC9121392 DOI: 10.1080/10826084.2020.1781179] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Overdose (OD) deaths have continued to rise in the United States posing a critical public health challenge. Various factors have been associated with increased likelihood of OD, including history of injection drug use. Purpose: This study examined multi-level factors associated with non-fatal OD among current people who inject drugs (PWID) in Appalachian Kentucky. Methods: This cross-sectional study utilized data from 324 PWID recruited via Respondent-Driven Sampling techniques in three Appalachian counties. The analysis focused on correlates of overdose history among people who inject drugs (PWID). Findings: Approximately 36.7% of our sample reported having overdosed in their lifetime, with only 21.4% currently having access to a naloxone kit for OD reversal. Respondents who had injected fentanyl alone or in combination with another drug (OR = 4.26, 95% CI= 2.31,7.86) had 4 times higher odds of an OD than those who did not. Our study found those who injected buprenorphine as primary drug (OR = 0.29, 95% CI = 0.10,0.81) had lower odds of OD compared to those who injected heroin. Conclusions/Importance: Given an increase in OD prevalence among PWID in the U.S, and especially among people living in the Appalachian region of Kentucky, assessing factors associated with OD is critical in development of tailored public health interventions to address the disparate rates of non-fatal OD in this vulnerable population.
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Affiliation(s)
- Janet K Otachi
- College of Nursing, University of Kentucky, Lexington, Kentucky, USA
| | - Nikita Vundi
- College of Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - Hilary L Surratt
- College of Medicine, University of Kentucky, Lexington, Kentucky, USA
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13
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Factors Associated With the Use of Supervised Consumption Facilities Among Women Who Inject Drugs in a Canadian Setting. J Addict Med 2020; 14:e226-e232. [PMID: 32142059 DOI: 10.1097/adm.0000000000000646] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Supervised consumption facilities (SCFs) are evidence-based harm reduction interventions that have been shown to reduce the risk of social and health-related harms associated with injection drug use. Previous qualitative studies have highlighted important motivations for SCF use among women who use drugs. However, factors associated with SCF use among women have not previously been evaluated. METHODS Data were obtained from 2 longitudinal community-recruited cohorts of people who use drugs in Vancouver, Canada between 2003 and 2017. Multivariable generalized estimating equations were used to calculate the odds of SCF use associated with social and structural risk factors for drug-related harm among women who reported injection drug use in the preceding 6-months. RESULTS A total of 795 participants were included in the study, contributing to 6302 interviews, with 602 participants (76%) reporting SCF use in at least one interview. Multivariable analysis demonstrated daily heroin and crystal methamphetamine injection (Adjusted Odds Ratio [AOR] = 1.32 and 1.65, respectively), injecting in public (AOR = 1.77), binge injection (AOR = 1.22) and lack of housing (AOR = 1.74) to be associated with SCF use. CONCLUSIONS The current study demonstrates higher intensity patterns of drug use, including daily heroin and crystal methamphetamine injection, injecting in public and binge injection, as well as homelessness to be associated with SCF use among women. Future research should identify barriers to SCF use among women to minimize the risk of overdose and other drug-related harms.
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14
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Keen C, Kinner SA, Borschmann R, Young JT. Comparing the predictive capability of self-report and medically-verified non-fatal overdose in adults released from prison: A prospective data linkage study. Drug Alcohol Depend 2020; 206:107742. [PMID: 31778949 DOI: 10.1016/j.drugalcdep.2019.107742] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 11/08/2019] [Accepted: 11/13/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Self-reported non-fatal overdose (NFOD) is a predictor of future overdose and is often used to target overdose prevention for people released from prison. However, the level of agreement between self-reported and medically-verified NFOD history remains unknown. This study aimed to determine the agreement between, and predictive value of, self-reported and medically-verified history of NFOD in people recently released from prison. METHODS Pre-release baseline survey data from 1307 adults in prison surveyed from 2008 to 2010 in Queensland, Australia were linked to ambulance, emergency department, and hospital records. We compared the agreement of self-reported NFOD history in the baseline survey and medically-verified NFOD ascertained through linked medical data. Unadjusted and adjusted regression models were used to determine the association between self-reported and medically verified NFOD history and medically-verified NFOD after release from prison. RESULTS 224 (19 %) participants self-reported NFOD history only, 75 (5 %) had medically-verified NFOD history only, and 56 (4 %) both self-reported and had medically-verified NFOD history. Compared to those with no NFOD history, those who self-reported and had a medical history of NFOD (adjusted hazard ratio (AHR) 6.1, 95 %CI 3.1-11.9), those with a medical history only (AHR 3.4, 95 %CI 1.7-7.0), and those who self-reported only (AHR 1.8, 95 %CI 1.0-3.5) were at increased risk of medically-verified NFOD after release from prison. CONCLUSIONS Relying on self-report of NFOD is likely to miss people at increased risk of future NFOD, many of whom could be identified through medical records. Wherever possible, data related to NFOD should be triangulated from multiple sources.
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Affiliation(s)
- Claire Keen
- Justice Health Unit, Centre for Health Equity, Melbourne School of Population and Global Health, The University of Melbourne, Parkville, Victoria, Australia.
| | - Stuart A Kinner
- Justice Health Unit, Centre for Health Equity, Melbourne School of Population and Global Health, The University of Melbourne, Parkville, Victoria, Australia; Centre for Adolescent Health, Murdoch Children's Research Institute, Parkville, Victoria, Australia; Mater Research Institute-UQ, University of Queensland, Brisbane, Queensland, Australia; Griffith Criminology Institute, Griffith University, Brisbane, Queensland, Australia; School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Rohan Borschmann
- Justice Health Unit, Centre for Health Equity, Melbourne School of Population and Global Health, The University of Melbourne, Parkville, Victoria, Australia; Centre for Adolescent Health, Murdoch Children's Research Institute, Parkville, Victoria, Australia; Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK; Melbourne School of Psychological Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Jesse T Young
- Justice Health Unit, Centre for Health Equity, Melbourne School of Population and Global Health, The University of Melbourne, Parkville, Victoria, Australia; Centre for Adolescent Health, Murdoch Children's Research Institute, Parkville, Victoria, Australia; School of Population and Global Health, The University of Western Australia, Perth, Western Australia, Australia; National Drug Research Institute, Curtin University, Perth, Western Australia, Australia
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15
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Keen C, Young JT, Borschmann R, Kinner SA. Non-fatal drug overdose after release from prison: A prospective data linkage study. Drug Alcohol Depend 2020; 206:107707. [PMID: 31757517 DOI: 10.1016/j.drugalcdep.2019.107707] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 10/10/2019] [Accepted: 10/21/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Adults released from prison are at increased risk of poor health outcomes and preventable mortality, including from overdose. Non-fatal overdose (NFOD) is a strong predictor of future overdose and associated with considerable morbidity. This study aims to the determine the incidence, predictors and clinical characteristics of NFOD following release from prison. METHODS We used pre-release interview data collected for a randomised controlled trial in 2008-2010, and linked person-level, state-wide ambulance, emergency department, and hospital records, from a representative sample of 1307 adults incarcerated in Queensland, Australia. The incidence of NFOD following release from prison was calculated. A multivariate Andersen-Gill model was used to identify demographic, health, social, and criminal justice predictors of NFOD. RESULTS The crude incidence rate (IR) of NFOD was 47.6 (95%CI 41.1-55.0) per 1000 person-years and was highest in the first 14 days after release from prison (IR = 296 per 1000 person-years, 95%CI 206-426). In multivariate analyses, NFOD after release from prison was positively associated with a recent history of substance use disorder (SUD), dual diagnosis of mental illness and SUD, lifetime history of injecting drug use, lifetime history of NFOD, being dispensed benzodiazepines after release, a shorter index incarceration, and low perceived social support. The risk of NFOD was lower for people with high-risk alcohol use and while incarcerated. CONCLUSIONS Adults released from prison are at high risk of non-fatal overdose, particularly in the first 14 days after release. Providing coordinated transitional care between prison and the community is likely critical to reduce the risk of overdose.
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Affiliation(s)
- Claire Keen
- Justice Health Unit, Centre for Health Equity, Melbourne School of Population and Global Health, The University of Melbourne, Parkville, Victoria, Australia.
| | - Jesse T Young
- Justice Health Unit, Centre for Health Equity, Melbourne School of Population and Global Health, The University of Melbourne, Parkville, Victoria, Australia; Centre for Adolescent Health, Murdoch Children's Research Institute, Parkville, Victoria, Australia; School of Population and Global Health, The University of Western Australia, Perth, Western Australia, Australia; National Drug Research Institute, Curtin University, Perth, Western Australia, Australia
| | - Rohan Borschmann
- Justice Health Unit, Centre for Health Equity, Melbourne School of Population and Global Health, The University of Melbourne, Parkville, Victoria, Australia; Centre for Adolescent Health, Murdoch Children's Research Institute, Parkville, Victoria, Australia; Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK; Melbourne School of Psychological Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Stuart A Kinner
- Justice Health Unit, Centre for Health Equity, Melbourne School of Population and Global Health, The University of Melbourne, Parkville, Victoria, Australia; Centre for Adolescent Health, Murdoch Children's Research Institute, Parkville, Victoria, Australia; Mater Research Institute-UQ, University of Queensland, Brisbane, Queensland, Australia; Griffith Criminology Institute, Griffith University, Brisbane, Queensland, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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16
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Brinkley-Rubinstein L, Cloud D, Drucker E, Zaller N. Opioid Use Among Those Who Have Criminal Justice Experience: Harm Reduction Strategies to Lessen HIV Risk. Curr HIV/AIDS Rep 2019; 15:255-258. [PMID: 29752698 DOI: 10.1007/s11904-018-0394-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
PURPOSE OF REVIEW We reviewed the HIV and opioid literature relevant to harm reduction strategies for those with criminal justice experience. RECENT FINDINGS Opioid use in the United States has risen at an alarming rate recently. This has led to increased numbers of people who inject drugs, placing new populations at risk for HIV, including those who have criminal justice experience. In recent years, there has been a gradual decrease in the number of individuals under the supervision of the criminal justice system. However, concurrently, there has been a rise in the number of individuals incarcerated in jails in rural counties that are at the center of the current opioid epidemic. We provide a number of harm reduction strategies that could be implemented in correctional settings such as access and linkage to medication-assisted treatment, connection to syringe exchange programs and safe injection facilities (where available), and the repackaging of pre-exposure prophylaxis as a harm reduction tool.
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Affiliation(s)
- Lauren Brinkley-Rubinstein
- Department of Social Medicine, University of North Carolina, Chapel Hill, NC, USA.
- Center for Health Equity Research, University of North Carolina, Chapel Hill, NC, USA.
| | - David Cloud
- Vera Institute of Justice, New York, NY, USA
- Department of Behavioral Sciences and Health Education, Emory University, Atlanta, GA, USA
| | - Ernest Drucker
- College of Public Health, New York University, New York, NY, USA
| | - Nickolas Zaller
- Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR, USA
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17
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Belackova V, Salmon AM, Day CA, Ritter A, Shanahan M, Hedrich D, Kerr T, Jauncey M. Drug consumption rooms: A systematic review of evaluation methodologies. Drug Alcohol Rev 2019; 38:406-422. [PMID: 30938025 DOI: 10.1111/dar.12919] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 01/16/2019] [Accepted: 02/12/2019] [Indexed: 01/27/2023]
Abstract
ISSUES Drug consumptions rooms (DCR) and supervised injecting facilities (SIF) are expanding internationally. Previous reviews have not systematically addressed evaluation methodologies. APPROACH Results from systematic searches of scientific databases in English until June 2017 were coded for paper type, country and year of publication. For evaluation papers, study outcome, methodology/study design and main indicators of DCR/SIF 'exposure' were recorded. KEY FINDINGS Two hundred and nineteen eligible peer-reviewed papers were published since 1999: the majority from Canada (n = 117 papers), Europe (n = 36) and Australia (n = 32). Fifty-six papers reported evaluation outcomes. Ecological study designs (n = 10) were used to assess the impact on overdose, public nuisance and crime; modelling techniques (n = 6) estimated impact on blood-borne diseases, overdose deaths and costs. Papers using individual-level data included four prospective cohorts (n = 28), cross-sectional surveys (n = 7) and service records (n = 5). Individual-level data were used to assess safer injecting practice, uptake into health and social services and all the other above outcomes except for impact on crime and costs. Four different indicators of DCR/SIF attendance were used to measure service 'exposure'. IMPLICATIONS Research around DCRs/SIFs has used ecological, modelling, cross-sectional and cohort study designs. Further research could involve systematic inclusion of a control group of people who are eligible but do not access SIFs, validation of self-reported proportion of injections at SIFs or a stepped-wedge or a cluster trial comparing localities. CONCLUSIONS Methodologies appropriate for DCR/SIF evaluation have been established and can be readily replicated from the existing literature. Research on operational aspects, implementation and transferability is also warranted.
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Affiliation(s)
| | - Allison M Salmon
- Uniting Medically Supervised Injecting Centre, Sydney, Australia
| | - Carolyn A Day
- Central Clinical School, Addiction Medicine, University of Sydney, Royal Prince Albert Hospital, Sydney, Australia
| | - Alison Ritter
- Drug Policy Modelling Program, UNSW Sydney, Sydney, Australia
| | - Marian Shanahan
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia
| | - Dagmar Hedrich
- European Monitoring Centre for Drugs and Drug Addiction, Lisbon, Portugal
| | - Thomas Kerr
- British Columbia Centre on Substance Use, Vancouver, Canada
| | - Marianne Jauncey
- Uniting Medically Supervised Injecting Centre, Sydney, Australia.,National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia
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18
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Hood JE, Behrends CN, Irwin A, Schackman BR, Chan D, Hartfield K, Hess J, Banta-Green C, Whiteside L, Finegood B, Duchin J. The projected costs and benefits of a supervised injection facility in Seattle, WA, USA. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2019; 67:9-18. [PMID: 30802842 DOI: 10.1016/j.drugpo.2018.12.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 12/06/2018] [Accepted: 12/30/2018] [Indexed: 12/30/2022]
Abstract
BACKGROUND As one strategy to improve the health and survival of people who inject drugs, the King County Heroin & Opioid Addiction Task Force recommended the establishment of supervised injection facilities (SIF) where people can inject drugs in a safe and hygienic environment with clinical supervision. Analyses for other sites have found them to be cost-effective, but it is not clear whether these findings are transferable to other settings. METHODS We utilized local estimates and other data sources deemed appropriate for our setting to implement a mathematical model that assesses the impact of a hypothetical SIF on overdose deaths, non-fatal overdose health service utilization, skin and soft tissue infections, bacterial infections, viral infections, and enrollment in medication assisted treatment (MAT). We estimated the costs and savings that would occur on an annual basis for a small-scale pilot site given current overdose rates, as well as three other scenarios of varying scale and underlying overdose rates. RESULTS Assuming current overdose rates, a hypothetical Seattle SIF in a pilot phase is projected to annually reverse 167 overdoses and prevent 6 overdose deaths, 45 hospitalizations, 90 emergency department visits, and 92 emergency medical service deployments. Additionally, the site would facilitate the enrollment of 41 SIF clients in medication assisted treatment programs. These health benefits correspond to a monetary value of $5,156,019. The annual estimated cost of running the SIF is $1,222,332. The corresponding cost-benefit ratio suggests that the pilot SIF would generate $4.22 for every dollar spent on SIF operational costs. The pilot SIF is projected to save the healthcare system $534,453. If Seattle experienced elevated overdose rates and Seattle SIF program were scaled up, the health benefits and financial value would be considerably greater. CONCLUSION This analysis suggests that a SIF program in Seattle would save lives and result in considerable health benefits and cost savings.
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Affiliation(s)
- J E Hood
- Public Health - Seattle & King County, 401 Fifth Avenue, Suite 1250, Seattle, WA, United States.
| | - C N Behrends
- Weill Cornell Medical College, 1300 York Ave. Box 65, New York, NY, 10065, United States
| | - A Irwin
- Law Enforcement Action Partnership, Silver Spring, MD, United States
| | - B R Schackman
- Weill Cornell Medical College, 1300 York Ave. Box 65, New York, NY, 10065, United States
| | - D Chan
- King County Department of Community and Health Services, 401 Fifth Avenue, Suite 500, Seattle, WA, United States; University of Washington, School of Public Health, 1959 NE Pacific St, Seattle, WA, 98195, United States
| | - K Hartfield
- Public Health - Seattle & King County, 401 Fifth Avenue, Suite 1250, Seattle, WA, United States
| | - J Hess
- University of Washington, School of Medicine, 1959 NE Pacific St, Seattle, WA, 98195, United States
| | - C Banta-Green
- University of Washington, School of Public Health, 1959 NE Pacific St, Seattle, WA, 98195, United States
| | - L Whiteside
- University of Washington, School of Medicine, 1959 NE Pacific St, Seattle, WA, 98195, United States
| | - B Finegood
- King County Department of Community and Health Services, 401 Fifth Avenue, Suite 500, Seattle, WA, United States
| | - J Duchin
- Public Health - Seattle & King County, 401 Fifth Avenue, Suite 1250, Seattle, WA, United States; University of Washington, School of Public Health, 1959 NE Pacific St, Seattle, WA, 98195, United States; University of Washington, School of Medicine, 1959 NE Pacific St, Seattle, WA, 98195, United States
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19
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Abstract
The US is facing dual public health crises related to opioid overdose deaths and HIV. Injection drug use is fueling both of these epidemics. The War on Drugs has failed to stem injection drug use and has contributed to mass incarceration, poverty, and racial disparities. Harm reduction is an alternative approach that seeks to decrease direct and indirect harms associated with drug use without necessarily decreasing drug consumption. Although overwhelming evidence demonstrates that harm reduction is effective in mitigating harms associated with drug use and is cost-effective in providing these benefits, harm reduction remains controversial and the ethical implications of harm reduction modalities have not been well explored. This paper analyzes harm reduction for injection drug use using the core principles of autonomy, nonmaleficence, beneficence, and justice from both clinical ethics and public health ethics perspectives. This framework is applied to harm reduction modalities currently in use in the US, including opioid maintenance therapy, needle and syringe exchange programs, and opioid overdose education and naloxone distribution. Harm reduction interventions employed outside of the US, including safer injection facilities, heroin-assisted treatment, and decriminalization/legalization are then discussed. This analysis concludes that harm reduction is ethically sound and should be an integral aspect of our nation's healthcare system for combating the opioid crisis. From a clinical ethics perspective, harm reduction promotes the autonomy of, prevents harms to, advances the well-being of, and upholds justice for persons who use drugs. From a public health ethics perspective, harm reduction advances health equity, addresses racial disparities, and serves vulnerable, disadvantaged populations in a cost-effective manner.
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20
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Madah-Amiri D, Skulberg AK, Braarud AC, Dale O, Heyerdahl F, Lobmaier P, Clausen T. Ambulance-attended opioid overdoses: An examination into overdose locations and the role of a safe injection facility. Subst Abus 2018; 40:383-388. [PMID: 29949448 DOI: 10.1080/08897077.2018.1485130] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Background: Although the United States and numerous other countries are amidst an opioid overdose crisis, access to safe injection facilities remains limited. Methods: We used prospective data from ambulance journals in Oslo, Norway, to describe the patterns, severity, and outcomes of opioid overdoses and compared these characteristics among various overdose locations. We also examined what role a safe injection facility may have had on these overdoses. Results: Based on 48,825 ambulance calls, 1054 were for opioid overdoses from 465 individuals during 2014 and 2015. The rate of calls for overdoses was 1 out of 48 of the total ambulance calls. Males made up the majority of the sample (n = 368, 79%), and the median age was 35 (range: 18-96). Overdoses occurred in public locations (n = 530, 50.3%), the safe injection facility (n = 353, 33.5%), in private homes (n = 83, 7.9%), and other locations (n = 88, 8.3%). Patients from the safe injection facility and private homes had similarly severe initial clinical symptoms (Glasgow Coma Scale median =3 and respiratory frequency median =4 breaths per minute) when compared with other locations, yet the majority from the safe injection facility did not require further ambulance transport to the hospital (n = 302, 85.6%). Those overdosed in public locations (odds ratio [OR] = 1.66, 95% confidence interval [CI] = 1.17-2.35), and when the safe injection facility was closed (OR =1.4, 95% CI =1.04-1.89), were more likely to receive transport for further treatment. Conclusions: Our findings suggest that the opening hours at the safe injection facility and the overdose location may impact the likelihood of ambulance transport for further treatment.
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Affiliation(s)
- Desiree Madah-Amiri
- The Norwegian Centre for Addiction Research, The University of Oslo, Oslo, Norway
| | - Arne Kristian Skulberg
- Department of Circulation and Medical Imaging, The Norwegian University of Science and Technology, Trondheim, Norway.,Department of Anesthesiology and Critical Care, Oslo University Hospital, Oslo, Norway
| | | | - Ola Dale
- Department of Circulation and Medical Imaging, The Norwegian University of Science and Technology, Trondheim, Norway.,St. Olav's Hospital, University Hospital of Trondheim, Trondheim, Norway
| | - Fridtjof Heyerdahl
- Department of Anesthesiology and Critical Care, Oslo University Hospital, Oslo, Norway
| | - Philipp Lobmaier
- The Norwegian Centre for Addiction Research, The University of Oslo, Oslo, Norway.,Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
| | - Thomas Clausen
- The Norwegian Centre for Addiction Research, The University of Oslo, Oslo, Norway
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21
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May T, Bennett T, Holloway K. RETRACTED: The impact of medically supervised injection centres on drug-related harms: a meta-analysis. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2018; 59:98-107. [PMID: 30077946 DOI: 10.1016/j.drugpo.2018.06.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Revised: 02/22/2018] [Accepted: 06/15/2018] [Indexed: 01/09/2023]
Affiliation(s)
- Tom May
- Centre for Criminology, University of South Wales, Pontypridd, CF37 1DL, United Kingdom
| | - Trevor Bennett
- Centre for Criminology, University of South Wales, Pontypridd, CF37 1DL, United Kingdom
| | - Katy Holloway
- Centre for Criminology, University of South Wales, Pontypridd, CF37 1DL, United Kingdom
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22
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Darke S, Duflou J, Lappin J, Kaye S. Clinical and Autopsy Characteristics of Fatal Methamphetamine Toxicity in Australia. J Forensic Sci 2017; 63:1466-1471. [PMID: 29193063 DOI: 10.1111/1556-4029.13710] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Revised: 11/08/2017] [Accepted: 11/09/2017] [Indexed: 12/22/2022]
Abstract
Characteristics of death attributed solely to methamphetamine toxicity (MT, n = 93) by forensic pathologists were examined and compared to cases of multiple drug toxicity (MDT, n = 634). The mean age of MT cases was 36.7 years, and 86.0% were male. Strenuous activity was reported in 12.9%. The most common witness observations were: collapse (60.3%), difficulty in breathing (36.2%), and hyperthermia (27.6%). MT cases had higher blood methamphetamine (0.54 vs. 0.11 mg/L) and amphetamine (0.04 vs. 0.02 mg/L) concentrations and lower likelihoods for opioids (12.5% vs. 80.9%), hypnosedatives (27.3 vs. 60.7%), antidepressants (14.8 vs. 29.8%), and antipsychotics (9.1 vs. 19.7%). MT cases had significantly heavier hearts than MDT cases (423.4 vs. 385.8 g) and were more likely to have cardiomegaly (37.1 vs. 20.4%) and replacement fibrosis (25.7 vs. 14.5%). The clinical picture was of a sudden cardiac event in a middle-aged man with a high methamphetamine concentration. Cardiovascular signs of heavy methamphetamine use are frequently seen.
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Affiliation(s)
- Shane Darke
- National Drug& Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia
| | - Johan Duflou
- National Drug& Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia.,Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Julia Lappin
- National Drug& Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia.,School of Psychiatry, University of New South Wales, Sydney, NSW, Australia
| | - Sharlene Kaye
- National Drug& Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia.,Justice Health and Forensic Mental Health Network, NSW Health, Sydney, NSW, Australia
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Bardwell G, Scheim A, Mitra S, Kerr T. Assessing support for supervised injection services among community stakeholders in London, Canada. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2017; 48:27-33. [DOI: 10.1016/j.drugpo.2017.05.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 03/18/2017] [Accepted: 05/02/2017] [Indexed: 11/26/2022]
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Public Health and Public Order Outcomes Associated with Supervised Drug Consumption Facilities: a Systematic Review. Curr HIV/AIDS Rep 2017; 14:161-183. [DOI: 10.1007/s11904-017-0363-y] [Citation(s) in RCA: 94] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Gaddis A, Kennedy MC, Nosova E, Milloy MJ, Hayashi K, Wood E, Kerr T. Use of on-site detoxification services co-located with a supervised injection facility. J Subst Abuse Treat 2017; 82:1-6. [PMID: 29021106 DOI: 10.1016/j.jsat.2017.08.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 08/04/2017] [Accepted: 08/07/2017] [Indexed: 11/20/2022]
Abstract
OBJECTIVES Supervised injection facilities (SIFs) are increasingly being implemented worldwide in response to the harms associated with injection drug use. Although SIFs have been shown to promote engagement of people who use injection drugs (PWID) with external health services, little is known about the potential of co-locating on-site detoxification services with SIFs. The aim of this study was to characterize use of detoxification services co-located at Insite, North America's first SIF, among PWID in Vancouver, Canada. METHODS Data were derived from two prospective cohorts of PWID in Vancouver, Canada between November 2010 and December 2012. Using multivariable generalized estimating equation logistic regression, we identified factors independently associated with reporting use of detoxification services at the SIF. RESULTS Among 1316 PWID, 147 (11.2%) reported enrolling in detoxification services co-located with the SIF at least once during the two year study period. In multivariable analyses, after adjustment for other potential cofounders, factors independently and positively associated with use of this service included residence<5 blocks from the SIF (Adjusted Odds Ratio [AOR]=1.70), enrollment in methadone maintenance therapy (AOR=1.90), public injection (AOR=1.53), binge injection (AOR=1.93), recent overdose (AOR=1.90) and frequent SIF use (AOR=8.15) (all p<0.05). DISCUSSION Use of on-site detoxification services offered at the SIF was common among PWID and associated with frequent SIF use and various markers of vulnerability and drug-related risk. These findings highlight the potential role of SIFs as a point of access to detoxification services for high-risk PWID. Future studies should examine if co-location leads to higher uptake of addiction services in comparison to services that create geographic or other obstacles.
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Affiliation(s)
- Andrew Gaddis
- Virginia Tech Carilion School of Medicine, 2 Riverside Circle, Roanoke, VA, USA, 24016; British Columbia Centre on Substance Use, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada.
| | - Mary Clare Kennedy
- British Columbia Centre on Substance Use, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada; School of Population and Public Health, University of British Columbia, 2206 E Mall, Vancouver, BC V6T 1Z9, Canada
| | - Ekaterina Nosova
- British Columbia Centre on Substance Use, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada
| | - M-J Milloy
- British Columbia Centre on Substance Use, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada; Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada
| | - Kanna Hayashi
- British Columbia Centre on Substance Use, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada; Faculty of Health Sciences, Simon Fraser University, 8888 University Drive, Burnaby, BC V5A 1S6, Canada
| | - Evan Wood
- British Columbia Centre on Substance Use, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada; Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada
| | - Thomas Kerr
- British Columbia Centre on Substance Use, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada; Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada.
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Vallance K, Pauly B, Wallace B, Chow C, Perkin K, Martin G, Zhao J, Stockwell T. Factors associated with public injection and nonfatal overdose among people who inject drugs in street-based settings. DRUGS-EDUCATION PREVENTION AND POLICY 2017. [DOI: 10.1080/09687637.2017.1351524] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Kate Vallance
- Centre for Addictions Research of BC, University of Victoria, Victoria, Canada
| | - Bernie Pauly
- Centre for Addictions Research of BC, University of Victoria, Victoria, Canada
| | - Bruce Wallace
- School of Social Work, University of Victoria, Victoria, Canada
| | | | - Kathleen Perkin
- Centre for Addictions Research of BC, University of Victoria, Victoria, Canada
| | - Gina Martin
- School of Medicine, University of St. Andrews, St. Andrews, UK
| | - Jinhui Zhao
- Centre for Addictions Research of BC, University of Victoria, Victoria, Canada
| | - Tim Stockwell
- Centre for Addictions Research of BC, University of Victoria, Victoria, Canada
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Irwin A, Jozaghi E, Bluthenthal RN, Kral AH. A Cost-Benefit Analysis of a Potential Supervised Injection Facility in San Francisco, California, USA. JOURNAL OF DRUG ISSUES 2016. [DOI: 10.1177/0022042616679829] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Supervised injection facilities (SIFs) have been shown to reduce infection, prevent overdose deaths, and increase treatment uptake. The United States is in the midst of an opioid epidemic, yet no sanctioned SIF currently operates in the United States. We estimate the economic costs and benefits of establishing a potential SIF in San Francisco using mathematical models that combine local public health data with previous research on the effects of existing SIFs. We consider potential savings from five outcomes: averted HIV and hepatitis C virus (HCV) infections, reduced skin and soft tissue infection (SSTI), averted overdose deaths, and increased medication-assisted treatment (MAT) uptake. We find that each dollar spent on a SIF would generate US$2.33 in savings, for total annual net savings of US$3.5 million for a single 13-booth SIF. Our analysis suggests that a SIF in San Francisco would not only be a cost-effective intervention but also a significant boost to the public health system.
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Affiliation(s)
- Amos Irwin
- Criminal Justice Policy Foundation, Silver Spring, MD, USA
- Law Enforcement Against Prohibition, Medford, MA, USA
| | - Ehsan Jozaghi
- BC Centre for Disease Control, University of British Columbia, Vancouver, Canada
| | | | - Alex H. Kral
- Research Triangle Institute, San Francisco, CA, USA
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Wolfson-Stofko B, Bennett AS, Elliott L, Curtis R. Drug use in business bathrooms: An exploratory study of manager encounters in New York City. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2016; 39:69-77. [PMID: 27768996 DOI: 10.1016/j.drugpo.2016.08.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 08/16/2016] [Accepted: 08/29/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Though public bathroom drug injection has been documented from the perspective of people who inject drugs, no research has explored the experiences of the business managers who oversee their business bathrooms and respond to drug use. These managers, by default, are first-responders in the event of a drug overdose and thus of intrinsic interest during the current epidemic of opioid-related overdoses in the United States. This exploratory study assists in elucidating the experiences that New York City business managers have with people who inject drugs, their paraphernalia, and their overdoses. METHODS A survey instrument was designed to collect data on manager encounters with drug use occurring in their business bathrooms. Recruitment was guided by convenience and purposive approaches. RESULTS More than half of managers interviewed (58%, n=50/86) encountered drug use in their business bathrooms, more than a third (34%) of these managers also found syringes, and the vast majority (90%) of managers had received no overdose recognition or naloxone training. Seven managers encountered unresponsive individuals who required emergency assistance. CONCLUSION The results from this study underscore the need for additional research on the experiences that community stakeholders have with public injection as well as educational outreach efforts among business managers. This research also suggests that there is need for a national dialogue about potential interventions, including expanded overdose recognition and naloxone training and supervised injection facilities (SIF)/drug consumption rooms (DCR), that could reduce public injection and its associated health risks.
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Affiliation(s)
- Brett Wolfson-Stofko
- National Development & Research Institute, Institute for Special Populations Research, 71 W. 23rd St., 4th Fl., New York, NY 10100, United States of America; Center for Drug Use and HIV/HCV Research, Rory Meyers College of Nursing, New York University, 433 First Avenue, New York, NY 10100, United States of America.
| | - Alex S Bennett
- National Development & Research Institute, Institute for Special Populations Research, 71 W. 23rd St., 4th Fl., New York, NY 10100, United States of America; Center for Drug Use and HIV/HCV Research, Rory Meyers College of Nursing, New York University, 433 First Avenue, New York, NY 10100, United States of America
| | - Luther Elliott
- National Development & Research Institute, Institute for Special Populations Research, 71 W. 23rd St., 4th Fl., New York, NY 10100, United States of America; Center for Drug Use and HIV/HCV Research, Rory Meyers College of Nursing, New York University, 433 First Avenue, New York, NY 10100, United States of America
| | - Ric Curtis
- John Jay College of Criminal Justice, City University of New York, Department of Law, Police Science and Criminal Justice Administration, and Department of Anthropology, 524 W. 59th St., New York, NY 10019, United States of America; Center for Drug Use and HIV/HCV Research, Rory Meyers College of Nursing, New York University, 433 First Avenue, New York, NY 10100, United States of America
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Lake S, Hayashi K, Buxton J, Milloy MJ, Dong H, Wood E, Montaner J, Kerr T. The effect of prescription opioid injection on the risk of non-fatal overdose among people who inject drugs. Drug Alcohol Depend 2015; 156:297-303. [PMID: 26454837 PMCID: PMC4633348 DOI: 10.1016/j.drugalcdep.2015.09.026] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Revised: 09/23/2015] [Accepted: 09/24/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVES Prescription opioid (PO) use by people who inject drugs (PWID) is a growing public health concern. Non-fatal overdose remains a leading source of morbidity among PWID, however, little is known about the relationship between PO injection and non-fatal overdose in this population. In this study we sought to examine the impact of PO injection on non-fatal overdose among PWID from Vancouver, Canada. METHODS Data were derived from two open prospective cohorts of PWID for the period of December, 2005 to May, 2014. Multivariable generalized estimating equations were used to examine the odds of overdose among those who injected: POs; heroin; and POs and heroin. RESULTS In total, 1660 PWID (33.7% women) participated in this study. In multivariable analyses, in comparison to those who were injecting non-opioid drugs, exclusive PO injection was not significantly associated with non-fatal overdose (adjusted odds ratio [AOR]: 1.17, 95% confidence interval [CI]: 0.74-1.86). The odds of non-fatal overdose were elevated for heroin injection (AOR: 1.72, 95% CI: 1.31-2.27), but were greatest for those who injected both heroin and POs (AOR: 2.46, 95% CI: 1.83-3.30). DISCUSSION Compared to injecting non-opioids, injecting POs exclusively did not increase risk of non-fatal overdose; however, injecting both POs and heroin doubled the risk. This may reflect consistencies in drug potency and composition when POs are used, as well as unique characteristics of exclusive PO injectors. Our findings call for the continued scale-up of evidence-based overdose prevention interventions for people who inject opioids, including POs.
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Affiliation(s)
- Stephanie Lake
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada; School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC V6T 1Z3, Canada
| | - Kanna Hayashi
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada; Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada
| | - Jane Buxton
- School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC V6T 1Z3, Canada
| | - M-J Milloy
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada; Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada
| | - Huiru Dong
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada
| | - Evan Wood
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada; Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada
| | - Julio Montaner
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada; Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada
| | - Thomas Kerr
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada; Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada.
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Winter RJ, Stoové M, Degenhardt L, Hellard ME, Spelman T, Jenkinson R, McCarthy DR, Kinner SA. Incidence and predictors of non-fatal drug overdose after release from prison among people who inject drugs in Queensland, Australia. Drug Alcohol Depend 2015; 153:43-9. [PMID: 26105708 DOI: 10.1016/j.drugalcdep.2015.06.011] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Revised: 05/23/2015] [Accepted: 06/04/2015] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Release from prison is a period of elevated risk for drug-related harms, particularly among people who inject drugs (PWID). Non-fatal overdose can cause serious morbidity and predicts future fatal overdose, however neither the incidence nor the risk factors for non-fatal overdose following release from prison are well understood. METHODS Structured health-related interviews were conducted with 1051 adult prisoners in Queensland, Australia prior to release and approximately 1, 3 and 6 months post-release. Incidence of self-reported overdose in the community was calculated for PWID and all prisoners for three discrete time periods. Negative binomial regression with robust error variance was used to identify pre-release predictors of overdose among PWID. RESULTS The incidence of reported overdose was highest between 1 and 3 months post-release (37.8 per 100 person-years (PY) among PWID; 24.5/100 PY among all ex-prisoners). In adjusted analyses, the risk of post-release non-fatal overdose was higher for PWID who reported: being unemployed for >6 months before prison, having been removed from family as a child, at least weekly use of benzodiazepines and/or pharmaceutical opiates in the 3 months prior to prison, and ever receiving opioid substitution therapy (OST). Pre-release psychological distress and a lifetime history of mental disorder also predicted overdose, whereas risky alcohol use in the year before prison was protective. CONCLUSIONS PWID have a high risk of overdose following release from prison. Imprisonment is an opportunity to initiate targeted preventive interventions such as OST, overdose prevention training and peer-delivered naloxone for those with a high risk profile.
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Affiliation(s)
- R J Winter
- Centre for Population Health, Burnet Institute, Australia; School of Public Health and Preventive Medicine, Monash University, Australia.
| | - M Stoové
- Centre for Population Health, Burnet Institute, Australia; School of Public Health and Preventive Medicine, Monash University, Australia
| | - L Degenhardt
- National Drug and Alcohol Research Centre, University of New South Wales, Australia; Melbourne School of Population and Global Health, University of Melbourne, Australia
| | - M E Hellard
- Centre for Population Health, Burnet Institute, Australia; School of Public Health and Preventive Medicine, Monash University, Australia
| | - T Spelman
- Centre for Population Health, Burnet Institute, Australia; School of Public Health and Preventive Medicine, Monash University, Australia; Victorian Infectious Diseases Service, Doherty Institute, Australia
| | - R Jenkinson
- Centre for Population Health, Burnet Institute, Australia; Australian Institute of Family Studies, Australia
| | - D R McCarthy
- Centre for Population Health, Burnet Institute, Australia
| | - S A Kinner
- School of Public Health and Preventive Medicine, Monash University, Australia; Melbourne School of Population and Global Health, University of Melbourne, Australia; School of Medicine, University of Queensland, Australia
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Mitra G, Wood E, Nguyen P, Kerr T, DeBeck K. Drug use patterns predict risk of non-fatal overdose among street-involved youth in a Canadian setting. Drug Alcohol Depend 2015; 153:135-9. [PMID: 26096535 PMCID: PMC4509965 DOI: 10.1016/j.drugalcdep.2015.05.035] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Revised: 05/15/2015] [Accepted: 05/23/2015] [Indexed: 01/27/2023]
Abstract
BACKGROUND Non-fatal drug overdose is a major cause of morbidity among people who use drugs, although few studies have examined this risk among street-involved youth. We sought to determine the risk factors associated with non-fatal overdose among Canadian street-involved youth who reported illicit drug use. METHODS Using data from a prospective cohort of street-involved youth in Vancouver, Canada, we identified youth without a history of overdose and employed Cox regression analyses to determine factors associated with time to non-fatal overdose between September 2005 and May 2012. RESULTS Among 615 participants, 98 (15.9%) reported a non-fatal overdose event during follow-up, resulting in an incidence density of 7.67 cases per 100 person-years. In multivariate Cox regression analyses, binge drug use (adjusted hazard ratio [AHR]=1.85; 95% confidence interval [CI]=1.20-2.84), non-injection crystal methamphetamine use (AHR=1.70; 95% CI=1.12-2.58), non-injection prescription opiate use (AHR=2.56; 95% CI=1.36-4.82), injection prescription opiate use (AHR=2.49; 95% CI=1.40-4.45) and injection heroin use (AHR=1.85; 95% CI=1.14-3.00) were positively associated with time to non-fatal overdose. Social, behavioural and demographic factors were not significantly associated with time to non-fatal overdose event. CONCLUSIONS Rates of non-fatal overdose were high among street-involved youth. Drug use patterns, in particular prescription opiate use, were associated with overdose. These findings underscore the importance of addiction treatment and prevention efforts aimed at reducing the risk of overdose among youth.
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Affiliation(s)
- Goldis Mitra
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - Evan Wood
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada; Division of AIDS, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Paul Nguyen
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - Thomas Kerr
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada; Division of AIDS, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Kora DeBeck
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada; School of Public Policy, Simon Fraser University, Burnaby, BC, Canada.
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Associations between childhood trauma and non-fatal overdose among people who inject drugs. Addict Behav 2015; 43:83-8. [PMID: 25588793 DOI: 10.1016/j.addbeh.2014.12.014] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Accepted: 12/22/2014] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Although people who inject drugs (IDU) remain at a high risk of accidental overdose, interventions that address overdose remain limited. Accordingly there is a continuing need to identify psychological and social factors that shape overdose risk. Despite being reported frequently among IDU, childhood trauma has received little attention as a potential risk factor for overdose. This study aims to evaluate relationships between non-fatal overdose and five forms of childhood maltreatment among a cohort of IDU in Vancouver, Canada. METHODS Data was obtained from two prospective cohorts of IDU between December 2005 and May 2013. Multivariate generalized estimating equations (GEEs) were used to explore relationships between five forms of childhood trauma and non-fatal overdose, adjusting for potential confounders. RESULTS During the study period, 1697 IDU, including 552 (32.5%) women, were followed up. At baseline, 1136 (67.0%) participants reported at least one form of childhood trauma, while 4-9% reported a non-fatal overdose at each semi-annual follow-up. In multivariate analyses, physical [adjusted odds ratio (AOR): 1.36, 95% confidence interval (CI): 1.08-1.71], sexual (AOR: 1.48, CI: 1.17-1.87), and emotional abuse (AOR: 1.54, CI: 1.22-1.93) and physical neglect (AOR: 1.28, CI: 1.01-1.62) were independently associated with non-fatal overdose (all p<0.05). CONCLUSIONS Childhood trauma was common among participants, and reporting an experience of trauma was positively associated with non-fatal overdose. These findings highlight the need to provide intensive overdose prevention to trauma survivors and to incorporate screening for childhood trauma into health and social programs tailored to IDU.
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Lake S, Wood E, Buxton J, Dong H, Montaner J, Kerr T. Prescription opioid use and non-fatal overdose in a cohort of injection drug users. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2015; 41:257-63. [PMID: 25699628 DOI: 10.3109/00952990.2014.998366] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND There is growing concern regarding rising rates of prescription drug-related deaths among the general North American population as well as increasing availability of illicitly obtained prescription opioids. Concurrently among people who inject drugs (IDU), illicit prescription opioid use has increased while non-fatal overdose remains a major source of morbidity. OBJECTIVES To evaluate whether the use of prescription opioids was associated with non-fatal overdose among IDU in Vancouver, Canada. METHODS Data was obtained from two open prospective cohorts of IDU between December 2005 and May 2013. We used generalized estimating equation (GEE) logistic regression to evaluate the association between prescription opioid use and non-fatal overdose, adjusting for various social, demographic, and behavioral factors. RESULTS There were 1614 IDU, including 541 (33.5%) women, who were recruited and included in this analysis. At baseline, 526 (32.6%) reported using prescription opioids and 118 (7.3%) reported experiencing an overdose in the previous six months. In a multivariable analysis, prescription opioid use remained independently associated with non-fatal overdose (adjusted odds ratio: 1.61, 95% confidence interval: 1.32-1.95), after adjusting for confounders. CONCLUSION We observed relatively high rates of prescription opioid use among IDU in this setting, and found an independent association between prescription opioid use and non-fatal overdose. Our data is likely representative of riskier substance use associated with those who use prescription opioids within our sample. Interventions to prevent and respond to overdoses should consider the higher risk profiles of IDU who use prescription opioids.
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Affiliation(s)
- Stephanie Lake
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital , Vancouver , BC
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Bazazi AR, Zelenev A, Fu JJ, Yee I, Kamarulzaman A, Altice FL. High prevalence of non-fatal overdose among people who inject drugs in Malaysia: Correlates of overdose and implications for overdose prevention from a cross-sectional study. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2014; 26:675-81. [PMID: 25532449 DOI: 10.1016/j.drugpo.2014.11.010] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Revised: 11/15/2014] [Accepted: 11/17/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Overdose is the leading cause of death among opioid users, but no data are available on overdose among people who inject drugs in Malaysia. We present the first estimates of the prevalence and correlates of recent non-fatal overdose among people who inject drugs in Malaysia. METHODS In 2010, 460 people who inject drugs were recruited using respondent-driven sampling (RDS) in Klang Valley to assess health outcomes associated with injection drug use. Self-reported history of non-fatal overdose in the previous 6 months was the primary outcome. Sociodemographic, behavioral and structural correlates of non-fatal overdose were assessed using multivariable logistic regression. RESULTS All 460 participants used opioids and nearly all (99.1%) met criteria for opioid dependence. Most injected daily (91.3%) and were male (96.3%) and ethnically Malay (90.4%). Overall, 20% of participants had overdosed in the prior 6 months, and 43.3% had ever overdosed. The RDS-adjusted estimate of the 6-month period prevalence of overdose was 12.3% (95% confidence interval [CI] 7.9-16.6%). Having injected for more years was associated with lower odds of overdose (adjusted odds ratio [AOR] 0.6 per 5 years of injection, CI: 0.5-0.7). Rushing an injection from fear of the police nearly doubled the odds of overdose (AOR 1.9, CI: 1.9-3.6). Alcohol use was associated with recent non-fatal overdose (AOR 2.1, CI: 1.1-4.2), as was methamphetamine use (AOR 2.3, CI: 1.3-4.6). When adjusting for past-month drug use, intermittent but not daily methadone use was associated with overdose (AOR 2.8, CI: 1.5-5.9). CONCLUSION This study reveals a large, previously undocumented burden of non-fatal overdose among people who inject drugs in Malaysia and highlights the need for interventions that might reduce the risk of overdose, such as continuous opioid substitution therapy, provision of naloxone to prevent fatal overdose, treatment of polysubstance use, and working with police to improve the risk environment.
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Affiliation(s)
- Alexander R Bazazi
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA; Department of Internal Medicine, Section of Infectious Diseases, AIDS Program, Yale School of Medicine, 135 College St., Suite 323, New Haven, CT 06510, USA.
| | - Alexei Zelenev
- Department of Internal Medicine, Section of Infectious Diseases, AIDS Program, Yale School of Medicine, 135 College St., Suite 323, New Haven, CT 06510, USA
| | - Jeannia J Fu
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA; Department of Internal Medicine, Section of Infectious Diseases, AIDS Program, Yale School of Medicine, 135 College St., Suite 323, New Haven, CT 06510, USA; Centre of Excellence for Research in AIDS (CERiA), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Ilias Yee
- Centre of Excellence for Research in AIDS (CERiA), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Adeeba Kamarulzaman
- Department of Internal Medicine, Section of Infectious Diseases, AIDS Program, Yale School of Medicine, 135 College St., Suite 323, New Haven, CT 06510, USA; Centre of Excellence for Research in AIDS (CERiA), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia; Infectious Diseases Unit, Faculty of Medicine, University of Malaya, Lembah Pantai, 50603 Kuala Lumpur, Malaysia
| | - Frederick L Altice
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA; Department of Internal Medicine, Section of Infectious Diseases, AIDS Program, Yale School of Medicine, 135 College St., Suite 323, New Haven, CT 06510, USA; Centre of Excellence for Research in AIDS (CERiA), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
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Potier C, Laprévote V, Dubois-Arber F, Cottencin O, Rolland B. Supervised injection services: what has been demonstrated? A systematic literature review. Drug Alcohol Depend 2014; 145:48-68. [PMID: 25456324 DOI: 10.1016/j.drugalcdep.2014.10.012] [Citation(s) in RCA: 319] [Impact Index Per Article: 31.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2014] [Revised: 10/14/2014] [Accepted: 10/14/2014] [Indexed: 12/18/2022]
Abstract
BACKGROUND Supervised injection services (SISs) have been developed to promote safer drug injection practices, enhance health-related behaviors among people who inject drugs (PWID), and connect PWID with external health and social services. Nevertheless, SISs have also been accused of fostering drug use and drug trafficking. AIMS To systematically collect and synthesize the currently available evidence regarding SIS-induced benefits and harm. METHODS A systematic review was performed via the PubMed, Web of Science, and ScienceDirect databases using the keyword algorithm [("supervised" or "safer") and ("injection" or "injecting" or "shooting" or "consumption") and ("facility" or "facilities" or "room" or "gallery" or "centre" or "site")]. RESULTS Seventy-five relevant articles were found. All studies converged to find that SISs were efficacious in attracting the most marginalized PWID, promoting safer injection conditions, enhancing access to primary health care, and reducing the overdose frequency. SISs were not found to increase drug injecting, drug trafficking or crime in the surrounding environments. SISs were found to be associated with reduced levels of public drug injections and dropped syringes. Of the articles, 85% originated from Vancouver or Sydney. CONCLUSION SISs have largely fulfilled their initial objectives without enhancing drug use or drug trafficking. Almost all of the studies found in this review were performed in Canada or Australia, whereas the majority of SISs are located in Europe. The implementation of new SISs in places with high rates of injection drug use and associated harms appears to be supported by evidence.
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Affiliation(s)
- Chloé Potier
- Department of Addiction Medicine, CHRU de Lille, Univ Lille Nord de France, F-59037 Lille, France; University of Lille 2, Faculty of Medicine, F-59045 Lille, France.
| | - Vincent Laprévote
- CHU Nancy, Maison des Addictions, Nancy F-54000, France; CHU Nancy, Centre d'Investigation Clinique CIC-INSERM 9501, Nancy F-54000, France
| | - Françoise Dubois-Arber
- Institute of Social and Preventive Medicine, University Hospital Center and University of Lausanne, Chemin de la Corniche 10, 1010 Lausanne, Switzerland
| | - Olivier Cottencin
- Department of Addiction Medicine, CHRU de Lille, Univ Lille Nord de France, F-59037 Lille, France; University of Lille 2, Faculty of Medicine, F-59045 Lille, France
| | - Benjamin Rolland
- Department of Addiction Medicine, CHRU de Lille, Univ Lille Nord de France, F-59037 Lille, France; University of Lille 2, Faculty of Medicine, F-59045 Lille, France
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McNeil R, Small W, Lampkin H, Shannon K, Kerr T. "People knew they could come here to get help": an ethnographic study of assisted injection practices at a peer-run 'unsanctioned' supervised drug consumption room in a Canadian setting. AIDS Behav 2014; 18:473-85. [PMID: 23797831 DOI: 10.1007/s10461-013-0540-y] [Citation(s) in RCA: 86] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
People who require help injecting are disproportionately vulnerable to drug-related harm, including HIV transmission. North America's only sanctioned SIF operates in Vancouver, Canada under an exemption to federal drug laws, which imposes operating regulations prohibiting assisted injections. In response, the Vancouver Area Network of Drug Users (VANDU) launched a peer-run unsanctioned SIF in which trained peer volunteers provide assisted injections to increase the coverage of supervised injection services and minimize drug-related harm. We undertook qualitative interviews (n = 23) and ethnographic observation (50 h) to explore how this facility shaped assisted injection practices. Findings indicated that VANDU reshaped the social, structural, and spatial contexts of assisted injection practices in a manner that minimized HIV and other health risks, while allowing people who require help injecting to escape drug scene violence. Findings underscore the need for changes to regulatory frameworks governing SIFs to ensure that they accommodate people who require help injecting.
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Affiliation(s)
- Ryan McNeil
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
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Havinga P, van der Velden C, de Gee A, van der Poel A. Differences in sociodemographic, drug use and health characteristics between never, former and current injecting, problematic hard-drug users in the Netherlands. Harm Reduct J 2014; 11:6. [PMID: 24524263 PMCID: PMC3926265 DOI: 10.1186/1477-7517-11-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Accepted: 01/30/2014] [Indexed: 01/15/2023] Open
Abstract
Background Injecting drug users are at increased risk for harmful effects compared to non-injecting drug users. Some studies have focused on differences in characteristics between these two groups (e.g., housing, overall health). However, no study has investigated the specific Dutch situation which in the last years has seen a decrease in homelessness among problematic hard-drug users and an increasing focus on physical health in low-threshold addiction care. The purpose of this study was to determine differences in sociodemographic, drug use and health characteristics between never-injecting (NIDUs), former-injecting (FIDUs) and current-injecting drug users (IDUs) and describe injecting practices. Methods A total of 202 problematic hard-drug users (NIDU = 64; FIDU = 76; IDU = 62) were recruited from 22 low-threshold care facilities, including drug consumption rooms, methadone maintenance treatment, heroin-assisted therapy, day shelter and/or night shelter, supported housing and day activity centres. Data were collected on-site through structured face-to-face interviews. Results Results indicate that IDUs represented a separate group of problematic hard-drug users, with distinct sociodemographic and drug use characteristics. Overall, IDUs appeared to be the group with least favourable characteristics (unstable housing/homelessness, illegal activities, polydrug use) and NIDUs appeared to have the most favourable characteristics (stable housing, help with debts, less polydrug use). The FIDU group lies somewhere in between. The three groups did not differ significantly in terms of health. Regarding injecting practices, results showed that majority of IDUs had injected drugs for over 10 years and IDUs injected heroin, cocaine, amphetamine and/or methadone in the past 6 months. Sharing syringes was not common. A quarter reported public injecting. Conclusions Unstable housing and homelessness are related to (former) injecting drug use, and stable housing is related to never-injecting drug use. Our study suggests that the number of ‘new’ IDUs is low. However, public injecting among IDUs is not uncommon and is associated with unstable housing. This emphasizes the potential of housing projects as a component of harm reduction measures. Therefore, prevention of (risks associated with) injecting drug use and supported housing programmes for problematic hard-drug users deserve the continuous attention of policymakers and professionals in low-threshold addiction care.
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Affiliation(s)
| | | | | | - Agnes van der Poel
- Network of Infectious Diseases and Harm Reduction, Trimbos Institute, P,O, Box 725, Utrecht 3500, AS, The Netherlands.
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Pabayo R, Alcantara C, Kawachi I, Wood E, Kerr T. The role of depression and social support in non-fatal drug overdose among a cohort of injection drug users in a Canadian setting. Drug Alcohol Depend 2013; 132:603-9. [PMID: 23647731 PMCID: PMC3770831 DOI: 10.1016/j.drugalcdep.2013.04.007] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2012] [Revised: 04/04/2013] [Accepted: 04/06/2013] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Non-fatal overdose remains a significant source of morbidity among people who inject drugs (IDU). Although depression and social support are important in shaping the health of IDU, little is known about the relationship between these factors and overdose. Therefore, we sought to determine whether depressive symptoms and social support predicted non-fatal overdose among IDU in a Canadian setting. METHODS Data were derived from three prospective cohorts of people who use drugs: the Vancouver Injection Drug Users Study (VIDUS), the ACCESS Cohort, and the At-Risk Youth Study (ARYS). Multilevel modeling was used to determine if depression and social support were significant predictors of non-fatal overdose across time. Analyses were stratified by sex. RESULTS There were 1931 participants included in this analysis, including 653 (33.8%) females and 69 (3.6%) youth 20 years old or younger. Depressed men (adjusted odds ratio [AOR]=1.53, 95% confidence intervals [CI]=1.25, 1.87) and women (adjusted odds ratio [AOR]=2.23, 95% confidence intervals [CI]=1.65, 3.00) were more likely to experience a non-fatal overdose. Further, among women, those who reported having 3 or more persons they could rely upon for social support were less likely to experience a non-fatal overdose (AOR=0.54, 95% CI 0.31, 0.93). CONCLUSION Although depression was a significant predictor of non-fatal drug overdose, social support was a significant predictor among women only. Possible strategies to prevent non-fatal overdose may include identifying IDU experiencing severe depressive symptoms and providing targeted mental health treatments and mobilizing interpersonal social support among IDU, especially among women.
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Affiliation(s)
- Roman Pabayo
- Department of Social and Behavioral Sciences, Harvard School of Public Health, 677 Huntington Avenue, Boston, MA 02115, USA.
| | - Carmela Alcantara
- Department of Medicine, Columbia University Medical Center, 622 West 168 Street, PH-9, Room 9-319, New York, NY, USA, 10032
| | - Ichiro Kawachi
- Department of Society, Human Development, and Health, Harvard School of Public Health, 677 Huntington Avenue, Boston, MA, USA, 02115
| | - Evan Wood
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, 608-1081 Burrard Street, Vancouver, BC, CANADA, V6Z 1Y6,School of Population and Public Health, University of British Columbia, 5804 Fairview Avenue, Vancouver, BC, CANADA, V6T 1Z3,Department of Medicine, University of British Columbia, St. Paul’s Hospital, 608-1081 Burrard Street, Vancouver, BC, CANADA, V6Z 1Y6
| | - Thomas Kerr
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, 608-1081 Burrard Street, Vancouver, BC, CANADA, V6Z 1Y6,School of Population and Public Health, University of British Columbia, 5804 Fairview Avenue, Vancouver, BC, CANADA, V6T 1Z3,Department of Medicine, University of British Columbia, St. Paul’s Hospital, 608-1081 Burrard Street, Vancouver, BC, CANADA, V6Z 1Y6
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Coffin PO, Sullivan SD. Cost-effectiveness of distributing naloxone to heroin users for lay overdose reversal in Russian cities. J Med Econ 2013; 16:1051-60. [PMID: 23730942 DOI: 10.3111/13696998.2013.811080] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To evaluate the cost-effectiveness of distributing naloxone to illicit opioid users for lay overdose reversal in Russian cities. METHOD This study adapted an integrated Markov and decision analytic model to Russian cities. The model took a lifetime, societal perspective, relied on published literature, and was calibrated to epidemiologic findings. RESULTS For each 20% of heroin users reached with naloxone distribution, the model predicted a 13.4% reduction in overdose deaths in the first 5 years and 7.6% over a lifetime; on probabilistic analysis, one death would be prevented for every 89 naloxone kits distributed (95% CI = 32-260). Naloxone distribution was cost-effective in all deterministic and probabilistic sensitivity analyses and cost-saving if resulting in a reduction in overdose events. Naloxone distribution increased costs by US$13 (95% CI = US$3-US$32) and QALYs by 0.137 (95% CI = 0.022-0.389) for an incremental cost of US$94 per QALY gained (95% CI = US$40-US$325). In a worst-case scenario where overdose was rarely witnessed and naloxone was rarely used, minimally effective, and expensive, the incremental cost was US$1987 per QALY gained. If national expenditures on drug-related HIV, tuberculosis, and criminal justice were applied to heroin users, the incremental cost was US$928 per QALY gained. CONCLUSIONS Naloxone distribution to heroin users for lay overdose reversal is highly likely to reduce overdose deaths in target communities and is robustly cost-effective, even within the constraints of this conservative model.
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Affiliation(s)
- Phillip O Coffin
- Substance Use Research Unit, San Francisco Department of Public Health, San Francisco, CA, USA
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Martin G, Vallance K, Macdonald S, Stockwell T, Ivsins A, Chow C, Michelow W, Duff C. Nonfatal overdose from alcohol and/or drugs among a sample of recreational drug users. JOURNAL OF SUBSTANCE USE 2013. [DOI: 10.3109/14659891.2013.784369] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Horyniak D, Higgs P, Jenkinson R, Degenhardt L, Stoové M, Kerr T, Hickman M, Aitken C, Dietze P. Establishing the Melbourne Injecting Drug User Cohort Study (MIX): rationale, methods, and baseline and twelve-month follow-up results. Harm Reduct J 2013; 10:11. [PMID: 23786848 PMCID: PMC3691755 DOI: 10.1186/1477-7517-10-11] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2012] [Accepted: 06/14/2013] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Cohort studies provide an excellent opportunity to monitor changes in behaviour and disease transmission over time. In Australia, cohort studies of people who inject drugs (PWID) have generally focused on older, in-treatment injectors, with only limited outcome measure data collected. In this study we specifically sought to recruit a sample of younger, largely out-of-treatment PWID, in order to study the trajectories of their drug use over time. METHODS Respondent driven sampling, traditional snowball sampling and street outreach methods were used to recruit heroin and amphetamine injectors from one outer-urban and two inner-urban regions of Melbourne, Australia. Information was collected on participants' demographic and social characteristics, drug use characteristics, drug market access patterns, health and social functioning, and health service utilisation. Participants are followed-up on an annual basis. RESULTS 688 PWID were recruited into the study. At baseline, the median age of participants was 27.6 years (IQR: 24.4 years - 29.6 years) and two-thirds (67%) were male. Participants reported injecting for a median of 10.2 years (range: 1.5 months - 21.2 years), with 11% having injected for three years or less. Limited education, unemployment and previous incarceration were common. The majority of participants (82%) reported recent heroin injection, and one third reported being enrolled in Opioid Substitution Therapy (OST) at recruitment. At 12 months follow-up 458 participants (71% of eligible participants) were retained in the study. There were few differences in demographic and drug-use characteristics of those lost to follow-up compared with those retained in the study, with attrition significantly associated with recruitment at an inner-urban location, male gender, and providing incomplete contact information at baseline. CONCLUSIONS Our efforts to recruit a sample of largely out-of-treatment PWID were limited by drug market characteristics at the time, where fluctuating heroin availability has led to large numbers of PWID accessing low-threshold OST. Nevertheless, this study of Australian injectors will provide valuable data on the natural history of drug use, along with risk and protective factors for adverse health outcomes associated with injecting drug use. Comprehensive follow-up procedures have led to good participant retention and limited attrition bias.
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Affiliation(s)
- Danielle Horyniak
- Centre for Population Health, Burnet Institute, 85 Commercial Rd, Melbourne, VIC 3004, Australia.
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Hyshka E, Bubela T, Wild TC. Prospects for scaling-up supervised injection facilities in Canada: the role of evidence in legal and political decision-making. Addiction 2013; 108:468-76. [PMID: 23286831 DOI: 10.1111/add.12064] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2012] [Revised: 10/22/2012] [Accepted: 11/13/2012] [Indexed: 11/29/2022]
Abstract
BACKGROUND North America's first supervised injection facility-Insite-opened in Vancouver in 2003 under a special federal legal exemption. Insite has faced significant political and legal opposition, which culminated in a recent Supreme Court of Canada ruling that ordered the federal Minister of Health to extend the facility's exemption and cited evidence that the facility is life-preserving and does not increase public disorder. Officials in several other cities have initiated or accelerated preparations for new facilities due to speculation that the ruling provides sufficient legal basis to expand supervised injection in Canada. However, a comprehensive assessment of the barriers and facilitators to supervised injection facility scale-up is lacking. METHODS This policy case study reviews a corpus of jurisprudence, legislation, scientific research and media texts to: describe the role of evidence in legal and political decision-making around Insite; analyze the implications of the Insite decision for new facilities; and discuss alternative avenues for supervised injection facility expansion. RESULTS The Insite decision does not simplify the path towards new supervised injection facilities, but nor does it does pose an insurmountable hurdle. Whether new facilities will be established depends largely upon how the Minister of Health interprets the ruling, the proponents' ability to demonstrate need and support from municipal and provincial governments and community members. Formally defining supervised injection as within nurses' scope of practice could further efforts to establish new facilities. CONCLUSION Additional court action may be required to establish a stable legal and policy basis for supervised injection facilities in Canada.
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Affiliation(s)
- Elaine Hyshka
- Addiction and Mental Health Research Laboratory, School of Public Health, University of Alberta, Edmonton, AB, Canada.
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Latkin C, Yang C, Ehrhardt B, Hulbert A. The epidemiology of finding a dead body: reports from inner-city Baltimore, Maryland US. Community Ment Health J 2013; 49:106-9. [PMID: 22297618 PMCID: PMC3406247 DOI: 10.1007/s10597-012-9492-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2011] [Accepted: 01/18/2012] [Indexed: 10/14/2022]
Abstract
In the US, there are no national statistics on encountering a dead body, which can be viewed as a measure of community health and a stressful life event. Participants for an HIV prevention intervention targeting drug users were recruited in areas of inner-city Baltimore, Maryland. Nine hundred and fifty-one respondents, most with a history of drug use, were asked "have you ever found a dead body?" and 17.0% reported they had. Leading causes of death were: violence (37%), natural causes (22.2%), drug overdose (21.6%), accidental death (3.1%), and suicide (2.5%). In multivariate logistic models, respondents with longer history of drug use and more roles in a drug economy were more likely to be exposed to a dead body. The study results suggest that this population has a high level of experiences with mortality associated with violence and drugs. To obtain a better understanding of community health, future studies should assess not only morbidity and mortality, but also how death and illness is experienced by the community.
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Affiliation(s)
- Carl Latkin
- Department of Health, Behavior and Society, The Johns Hopkins Bloomberg School of Public Health, 624 North Broadway, Baltimore, MD 21205, USA.
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Martinez AN, D’Amico EJ, Kral AH, Bluthenthal RN. Nonmedical Prescription Drug Use Among Injection Drug Users. JOURNAL OF DRUG ISSUES 2012. [DOI: 10.1177/0022042612456015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This study described the prevalence and risk factors for nonmedical prescription drug use (NMPD) among injection drug users (IDUs) recruited at syringe exchange programs (SEPs) in California. Interviews were conducted with 1,586 IDUs recruited from 24 SEPs across three annual cross-sections between 2001 and 2003. Any NMPD use in the past 6 months was reported by 17% of the sample. Factors independently associated with depressant use include recent participation in a drug treatment program, recent injection of heroin, and frequency of injection. Factors independently associated with opioid use include frequency of injection and history of incarceration. NMPD depressant use increased the odds of a nonfatal overdose in the past year. The authors’ findings represent a first step toward creating an epidemiologic profile of NMPD use that may be useful for targeting the implementation of interventions that are effective in reducing overdoses, a significant cause of mortality among IDUs worldwide.
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Affiliation(s)
| | - Elizabeth J. D’Amico
- Health Program and Drug Policy Research Center, RAND Corporation, Santa Monica, CA, USA
| | - Alex H. Kral
- Urban Health Program, RTI International, San Francisco Regional Office, CA, USA
- University of California, San Francisco, USA
| | - Ricky N. Bluthenthal
- Institute for Prevention Research, University of Southern California, Los Angeles, USA
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Potential role of safer injection facilities in reducing HIV and hepatitis C infections and overdose mortality in the United States. Drug Alcohol Depend 2011; 118:100-10. [PMID: 21515001 DOI: 10.1016/j.drugalcdep.2011.03.006] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2011] [Revised: 03/08/2011] [Accepted: 03/09/2011] [Indexed: 10/18/2022]
Abstract
BACKGROUND Safer injection facilities (SIFs) reduce risks associated with injecting drugs, particularly public injection and overdose mortality. They exist in many countries, but do not exist in the United States. We assessed several ethical, operational, and public health considerations for establishing SIFs in the United States. METHOD We used the six-factor Kass framework (goals, effectiveness, concerns, minimization of concerns, fair implementation, and balancing of benefits and concerns), summarized needs of persons who inject drugs in the United States, and reviewed global evidence for SIFs. RESULTS SIFs offer a hygienic environment to inject drugs, provide sterile injection equipment at time of injection, and allow for safe disposal of used equipment. Injection of pre-obtained drugs, purchased by persons who inject drugs, happens in a facility where trained personnel provide on-site counseling and referral to addiction treatment and health care and intervene in overdose emergency situations. SIFs provide positive health benefits (reducing transmission of HIV and viral hepatitis, bacterial infections, and overdose mortality) without evidence for negative health or social consequences. SIFs serve most-at-risk persons, including those who inject in public or inject frequently, and those who do not use other public health programs. It is critical to address legal, ethical, and local concerns, develop and implement relevant policies and procedures, and assess individual- and community-level needs and benefits of SIFs given local epidemiologic data. CONCLUSIONS SIFs have the potential to reduce viral and bacterial infections and overdose mortality among those who engage in high-risk injection behaviors by offering unique public health services that are complementary to other interventions.
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Reddon H, Wood E, Tyndall M, Lai C, Hogg R, Montaner J, Kerr T. Use of North America's first medically supervised safer injecting facility among HIV-positive injection drug users. AIDS EDUCATION AND PREVENTION : OFFICIAL PUBLICATION OF THE INTERNATIONAL SOCIETY FOR AIDS EDUCATION 2011; 23:412-422. [PMID: 22010805 PMCID: PMC3799861 DOI: 10.1521/aeap.2011.23.5.412] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
The objective of this study was to examine supervised injecting facility (SIF) use among a cohort of 395 HIV-positive injection drug users (IDUs) in Vancouver, Canada. The correlates of SIF use were identified using generalized estimating equation analyses. In multivariate analyses, frequent SIF use was associated with homelessness (adjusted odds ratio [AOR] = 1.90), daily heroin injection (AOR = 1.56), and daily cocaine injection (AOR = 1.59). The reasons given for not using the SIF included a preference for injecting at home and already having a safe place to inject. The SIF services most commonly used were needle exchange and nursing services. The SIF appears to have attracted a high-risk subpopulation of HIV-positive IDUs; this coverage perhaps could be extended with the addition of HIV-specific services such as disease monitoring and the provision of antiretroviral therapy.
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Affiliation(s)
- Hudson Reddon
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, Vancouver, British Columbia, Canada
| | - Evan Wood
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, Vancouver, British Columbia, Canada
- Department of Medicine, University of British Columbia, Vancouver
| | - Mark Tyndall
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, Vancouver, British Columbia, Canada
- Department of Medicine, University of British Columbia, Vancouver
| | - Calvin Lai
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, Vancouver, British Columbia, Canada
| | - Robert Hogg
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, Vancouver, British Columbia, Canada
- Faculty of Health Sciences, Simon Fraser University, Vancouver
| | - Julio Montaner
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, Vancouver, British Columbia, Canada
- Department of Medicine, University of British Columbia, Vancouver
| | - Thomas Kerr
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, Vancouver, British Columbia, Canada
- Department of Medicine, University of British Columbia, Vancouver
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The prospect of implementing a Safer Injection Facility in San Francisco: Perspectives of community stakeholders. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2011; 22:239-41. [DOI: 10.1016/j.drugpo.2011.01.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2010] [Revised: 12/17/2010] [Accepted: 01/12/2011] [Indexed: 11/21/2022]
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Havens JR, Oser CB, Knudsen HK, Lofwall M, Stoops WW, Walsh SL, Leukefeld CG, Kral AH. Individual and network factors associated with non-fatal overdose among rural Appalachian drug users. Drug Alcohol Depend 2011; 115:107-12. [PMID: 21126831 PMCID: PMC3056907 DOI: 10.1016/j.drugalcdep.2010.11.003] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2010] [Revised: 10/21/2010] [Accepted: 11/01/2010] [Indexed: 11/18/2022]
Abstract
BACKGROUND Fatal overdoses involving prescription opioids have increased significantly in recent years in the United States--especially in rural areas. However, there are scant data about non-fatal overdose among rural drug users. The purpose of this study is to examine the prevalence and correlates of non-fatal overdose and witnessed overdose among rural Appalachian drug users. METHODS Rural drug users were participants in a longitudinal study of social networks and HIV transmission. An interviewer-administered questionnaire elicited information in the following domains: sociodemographic characteristics, drug use (including lifetime overdose and witnessed overdose), psychiatric disorders, HIV risk behaviors and social networks (support, drug and sex networks). Negative binomial regression was used to model the number of lifetime overdoses and witnessed overdoses. RESULTS Of the 400 participants, 28% had ever experienced a non-fatal overdose, while 58.2% had ever witnessed an overdose (fatal or non-fatal). Factors independently associated with a greater number of overdoses included having ever been in drug treatment, past 30-day injection of prescription opioids, meeting the criteria for post-traumatic stress disorder and/or antisocial personality disorder and having more members in one's support network. CONCLUSIONS Rural drug users with history of overdose were more likely to have injected with prescription opioids--which is different from urban heroin users. However, the remaining correlates of non-fatal overdose among this cohort of rural drug users were similar to those of urban heroin users, which suggests current overdose prevention strategies employed in urban settings may be effective in preventing fatal overdose in this population.
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Affiliation(s)
- Jennifer R Havens
- Center on Drug and Alcohol Research, University of Kentucky College of Medicine, Lexington, KY 40504, United States.
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Milloy MJ, Wood E, Reading C, Kane D, Montaner J, Kerr T. Elevated overdose mortality rates among First Nations individuals in a Canadian setting: a population-based analysis. Addiction 2010; 105:1962-70. [PMID: 20825372 DOI: 10.1111/j.1360-0443.2010.03077.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIMS To determine the total burden of illicit drug overdose mortality over the study period in the province of British Columbia and investigate possible population-level determinants by estimating rates among subgroups including First Nations individuals. DESIGN Review of coroner case files. SETTING The province of British Columbia, Canada. PARTICIPANTS Individuals dying from an illicit drug overdose between 2001 and 2005. MEASUREMENTS Age-adjusted mortality rates, standardized mortality ratios (SMR) and years of potential life lost (YPLL), stratified by major population groups. FINDINGS Over the study period, 909 individuals died from illicit drug overdoses, including 104 (11.4%) First Nations individuals. Compared to the general population, First Nations males and females suffered from substantially elevated SMR and YPLL. In a multivariate logistic regression analysis, First Nations deaths were significantly more likely to be among women, related to injection drug use and to have occurred in the Downtown Eastside area of Vancouver, the local epicentre of human immunodeficiency virus infection and open drug use (all P< 0.05). CONCLUSIONS This report found highly elevated overdose death rates and levels of premature mortality among First Nations Canadians in British Columbia compared to the general population. While previously unidentified, these findings are consistent with the poorer population health profile of First Nations Canadians. Although further research is needed to identify the causes of the elevated death rates, our findings support increased availability of evidence-based overdose prevention measures.
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Affiliation(s)
- M-J Milloy
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada, British Columbia
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Lloyd-Smith E, Wood E, Zhang R, Tyndall MW, Sheps S, Montaner JSG, Kerr T. Determinants of hospitalization for a cutaneous injection-related infection among injection drug users: a cohort study. BMC Public Health 2010; 10:327. [PMID: 20534148 PMCID: PMC2890691 DOI: 10.1186/1471-2458-10-327] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2009] [Accepted: 06/09/2010] [Indexed: 12/02/2022] Open
Abstract
Astract
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Affiliation(s)
- Elisa Lloyd-Smith
- British Columbia Centre for Excellence in HIV/AIDS, Providence Health Care, 608-1081 Burrard Street, Vancouver, V6Z 1Y6, Canada
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